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HomeMy WebLinkAbout0044 GEMINI DRIVE - Health 44 Gemini Drive W. Barnstable CP A = 131 052 Sep. 18, 2017 10:47AM No, 5207 P. 1 }�op11.4' CERTIFICATE OF ANALYSIS Page: 1 of 1 s66-- m Barnstable County Health Laboratory (M-MA009) fr SW�ro Report Prepared For: Report Dated: 9/12/2017 - r„ emu: Jean Schiffmann ND Bayview Real Estate Order No.: G17103130 1113 3220 Main Street, P 0 Box 165 Barnstable, MA 02630 �u Laboratory_ID#: 11103130-01 Description: Water- Drinking Water Sample tl: Sample Location: 44 Gemini Dr.,W.Barnstable Collected: 09/05/2017 Collected by: Customer Received: 09/05/2017 Routine ITEM RESULT UNITS RL MCL METHOD 9 ANALYS T TESTED NOTE Nitrate as Nitrogen ND mg/L 0.10 10 EPA 300.0 LAP 9/6/2017 Copper 0.16 mg/L 0.10 1.3 5M 31118 LAP 9/8/2017 Iron ND Mg/L 0.10 0.3 SM 3111E LAP 9/e/2017 pH 615 PH AT 26C NA 6.5-8.6 SM 4500-H-B DCB 9/5/2017 Sodium 26 mg/L 2.5 20 SM3111B LAP 9/8/2017 Total Col'rform Absent PIA 0 0 SM 9223B RG 9/6/2017 Conductance 210 Urnohs/cm 2.0 EPA 120.1• DCB 9/62017 1 Sodium level is above the maxlum contaminant level. Those on a low sodium dlet may wish to consult a physician. Attached please find the laboratory certified parameter list Approved B (Lab Dlrector) ND=None Detected RL = Reporting Limit MCL=Maximum Contaminant Level 3195 Main Street, PO. Box 427, Barnstable, MA 02630 Ph: 506-375-6605 Sep. 18. 2017 10:47AM No, 5207 P. 2 CERTIFICATE OF ANALYSIS Barnstable.County Health Laboratory (M-MA009) Recipient: Jean Schiffmann Matrbx: Water-DrinIdng Water Bayvlew Real Estate Sampled: 09/05/2017 8.25 3220 Maln Street, P 0 Box 165 Received: 09/09/2017 10:51 Barnstable, MA 02630 Collection Address: 44 Gemini Dr.,W.Bamstable Order#: Ci17103130� Sample Location: lab ID: 17103130-01 Destrlption: Real Estate Kit Date Analyzed: 9/6/2017 p 10:02 Sample#: Analyst: yn Method: EPA 524.2 Dilution Factor: 1 Comment: Sodium level Is above the rnMum contaminant level.Those on a low sodium diet may wish to consult a physician. EPA 524.2 - Volatile Organics by GC/MS -_ Result MCL MDL Result L MDL Parameter ug/L ug/L ug/L Parameter ug/L ug/L ug/L Dichlorodifluoromethane NID 0.50 Chloroform 0.81 80 0.50 loromethane ND 0.50 ds-1,2-bichloroethene ND 70 0.50 Vinyl chloride _ ND~ 2.0 0.50 is-1,3-Dichloropropene _ ND 0.50 Bromomethane _ ND 0.50 bibromochloromethane ND _ 0•50 pi,i,1,2-Tefrachloroethane _ ND 0.50 Dlbromomethane ND 0.50 4,1,1-Trichloroethane ND 200. 0.50 T Ethylbenzene ND 700 - 0.50 1,1,2,2-Tetrachloroethane ND 0.50 Hexachlorobutadiene ND also ,1,1,2-Tdchloroethane ND_ 5.0 0.50 Isopropylbenzene Nb also '1,1-Dlchloroethane _ ND 0.50 Methylene chloride _ ND 5.0 0.50 1,1-Dichloroethene ND 7.0 0.50 Methyl-tert-butyl ether _ ND 0.50 1,1-Dichlompropene _ ND 0.50 Naphthalene ND 0.50 1,2,3-Tdchlorobenzene ' ND 0.50 n-Butylbenzene ND 0.50 1,2,3-Trichloropropane ND 0.50 n-Propylbenzene ND 0.50 1,2,4-Trichlorobenzene ND 70 0.50 p-Isopropyitoluene ND 0.50 1,2,4-Trimethylbenzene ND 0.50 sec-Burylbenzene ND 0•50• 1,2-Dibrom6-3-chloropropane NO 0.50 Styrene ND 100 0.50 1,2-Dibromoethane(EDB) ND 0.50 tert-Butylbenzene ND 0.501,2-Dichlorobenzene ND 600 0.50 Tetrachloroethene ND 5.0 0.50 000 0.50 s.0 0.50 Toluene . ND 1 1,2-Dichloroefliarie ND _ ._ _ 1,2-Dichloropropane ND Total4enes ND 10000 0.50 1,3,5-Trlmethylbenzene ND 0.50 ins-1,2-Dichloroethene ND 100 0.50 1,3-DicNorobenzene ND 0.50 trans-1,3-Dichloropropene ND 0.50 1,3-Dichloropropane ND 0.50 richloroethene ND 5.0 0.50 1,4-Dlchlorobenzene ND 5.0 0.50 richlorofluoromethane ND 0.50 2,2-DIchloropropane ND 0.50 Surrogates %Recovered QC omits(%) 2-Chiorotoluene ND 0.50 p-Bromofluorobenzene 102% 70 1 130 4 Chlorotoluene ND 0.50 2.Dlchlorobenzene-d4 103% 70 j 130 Benzene ND 5.0 0.50 Bromobenzene ND 0.50 6romochloromet bane ND Mo Bromodlchloromethane ND aso bromoform _ ND 0.5o Carbon tetrachloride ND 5.0 0.50 Chiorobenzene ND 100 0.50 Chloroethane Altached please find the laboratory certified parameter list. Approved By, - (Lab Director) ND=None Detected RL Reporting Llmlt MCL•X Ma um Gonta Inant Le el n Ph: 508-375-6605 Pa e 1 of l 3995 Maln Street, PO. Box 427, Barnstable, MA 02630 9 4 - BAYVIEW REAL ESTATE "On a clear day you can see forever." 7 a; Tel: 508-362-8543 • Fax: 508-362-4786 3220 Route 6A, P.O. Box 165 • Barnstable, MA 02630 r k 4 CERTIFICATE OF ANALYSIS Page: 1 Barnstable County Health Laboratory ACttu Report Dated: 5/3/2004 Resort Preuared For: Richard F. Schiffmann Order No.: G0424858 Bayview Real Estate P.0. Box 165 Bamstable, MA 02630 Laboratory ID#: 0424858-01 Description: Water-Drinking Water Sample#: 24858 Sampling Location 44 Gemini Dr W Barnstable MA Collected: 4/20/2004 Collected by: T Schiffmann Received: 4/21/2004 Routine ITEM RESULT UNITS RL MCL Method# Analyst Tested Note LAB: IC Lab Nitrates <0.1 mg/L 0.1 10 EPA 300.0 LAP 4/22/2004 LAB: Metals Copper 0.4 mg/L 0.1 1.3 SM 3111B LAP 4/26/2004 Iron <0.1 mg/L 0.1 0.3 SM 311113 LAP 4/26/2004 Sodium 18 mg/L 1.0 20 SM 3111B LAP 4/26/2004 LAB: Microbiology Total Coliform Absent P/A 0 Absent 309 D 4/21/2004 LAB: Physical Chemistry Conductance 170 umohs/em 1 EPA 120.1 MHS 4/21/2004 pH 6.1 pH-units 0 EPA 150.1 MHS 4/21/2004 Water sample meets the recommended limits for drinking water of all the above tested parameters. f Approved By: < (Lab ctor) ld3a H-LIV31-i 318b1SNZlbB J0 NMOl a3AI33�� Superior Court House, PO.Box 427, Barnstable, MA 02630 Ph: 508-375-6605 I I OF AARy3> i0 M CERTIFICATE OF ANALYSIS Page: 1 i `g Barnstable County Health Laboratory Report Dated: 5/3/2004 Report Prepared For: Richard F. Schiffmann Order No.: G0424858 Bayview Real Estate P.0. Box 165 Bamstable, MA 02630 Laboratory ID#: 0424858-01 Description: Water-Drinking Water I Sample#: 24858 Sampling Location 44 Gemini Dr W Barnstable MA Collected: 4/20/2004 Collected by: T Schiffmann Received: 4/21/2004 i Routine ITEM RESULT UNITS RL MCL Method# Analvst Tested Note LAB: IC Lab Nitrates <0,1 mg/L 0.1 10 EPA 300.0 LAP 4/22/2004 i LAB: Metals I Copper 0.4 mg/L 0.1 1.3 SM 3111B LAP 4/26/2004 Iron <0,1 mg/L 0.1 0.3 SM 3111B LAP 4/26/2004 Sodium 18 mg/L 1.0 20 SM 311113 LAP 4/26/2004 LAB: Microbiology I Total Coliform Absent P/A 0 Absent 309 D 4/21/2004 i LAB: Physical Chemistry I. Conductance 170 umohs/cm 1 EPA 120.1 MHS 4/21/2004 pH 6.1, pH-units 0 EPA 150.1 MHS 4/21/2004 Water sample meets the recommended limits for drinking water of all the above tested parameters. Approved By: (Lab ctor) RECEIVED �.. . .. ._L. .. MAY 10 2004 .Ault TOWN OF BARNSTABLE HEALTH DEPT. ;i Superior Court House, PO. Box 427, Barnstable, MA 02630 Ph: 508-375-6605 COMMONWEALTH OF MASSACHUSETTS ` 0 EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS E DEPARTMENT OF ENVIRONMENTAL PROTECTION m fAAP 131 PARCEL , LOT TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS s SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM g PART A —� CERTIFICATION cO Property Address: 77 lire►^7/0 t' y 4 Owner's Name: OS Ca ✓• Owner's Address: 4 G vim, Ori .1�0Q t4ln, Date of Ins pection: XIL�n d? 11 j'-Name of Inspector: (please print) /" /S /� how NP`gH P t e Company Name: yyi o � TIC(f Mailing Address: Imo 19o.X 1,4 Telephone Number: o CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported Lbelow is true,accurate and complete as of the time of the inspection.The inspection was performed based on my %4 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.M of Title 5(310 CMR 15.000). The system: `1 F-1?, t AL fr P m 1i _ b tot., Conditionally Passes 9ta b to " Needs Further Evaluation by the Local Approving Authority 4,0 Fails ibX,n w\c 4 Inspector's Signature: Date: Zvi b 3 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 DER The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. , Notes and Comments l�T ��'�T�+�e needs Alit *ec e ****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. r Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 111,4 b—ef1i i ri Owner: w ✓ Date of Inspection: O O Inspection Summary: Check A,B,C,D or E/ALWAYS complete an of Section D A. Sy Passes: G have not found any rnforngatron which indicates that any of the failure cxiUerid described in 310 CNIlt 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Dually Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not deb=nined"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is struehuaffy unsound,exhibits substantial infiltration or extiltration 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 owturdlly sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pepe(s)or due to a broken,settled or uneven distribution box System will pass inspection if(with approval of Board of Health): broken pipes)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pun43mg more than 4 times a year due to broken or obstructed pripe(s).The system will pass inspection if(with approval of the Board of Health): broken pipes)are replaced obstruction is removed ND explain: / C)(/1 (� � �L Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Owner. h Date of Inspection: 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 CM 1&303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ 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 I 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 pmvate water supply well**.Method used to determine distance **This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 plan,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 4 r,17 e �''� e� O')L 6 6�7 Owner: --; fe /, Date of Inspection: 4a 1 Zo Q7 D. System Failure Criteria applicable to all systems: You most indicate`des"or"no"to each of the following for At inspections: Yes No _ -vaadmp of sewage into facility or system component due to overloaded or clogged SAS or cesspool _ or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool lafc liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or 1 quid depth in cesspool is less than 6"below invert or available volume is less than%day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number ��Jol times pumped 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. portion of a cesspool or privy is within a Zone 1 of a public well. portion of a cesspool or privy is within 50 feet of a private water supply well. Ary portion of a cesspool or privy is less than 100 feet tart greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] (Ym 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 faihre. L Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gPd You must indicate either`yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no — the system is within 400 feet of a surface ddnldng 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 Wred"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 that under Section E or failed under Section D shall upgrade the system in accordance with 310 CNR 15.304.The system owner should contact the appropriate regional office of the Department, I Page 5 of I I OFFICIAL INSPECTION FORM-NOT FOR VOL UNTARY AS SESSMENTS SSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B / CHECKLIST Property Address: �tlIr► Owner: u�� o /� od,6 ,67 Date of Inspection• Check if the following have been done.You must indicate`Yes"or"no"as to each of the following: Y�e % L Pig information was prided hY the or Board of Health — — W nay of the system components pined out in the previous two weeks Has system received normal flows m the previous two week period Have large volumes of water been ifrodueed 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 beck up " as the site inspected for signs of break out were all system componeri%,excluding the SAS,located on site V17- Were of the the septic tank manholes uncovered,wed,and the iatmiur•of the tank Inspected forthe condition es ortees,material of construction,&mensi0'1s,depth of liquid,depth of sludge and depth of scum _ was the fae14 owner(and oc upanis if d}fferent from owner)provided with information on the proper me of subsurflace sewage disposal systems The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes Existing information.For example,a plan at the Board of Health. _ Detemrined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)P 10 CMR I5.302(3)(b)j Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address• i h, • Pl G r✓► ., /yam �oL6' Owner: k.-,- Date of Inspection: O FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):-.L Number of bedrooms(actual): 3 DESIGN flow based on 310 CUR 15.203(for example: 110 gpd x#of bedrooms): O Number of current residents: O Does residence have a garbage grinder(yes or no):/A Is laundry on a separate sewage system, or no):-!p [if yes separate inspection requirtA LamXhy es or no): Seasonal use:(yes or no): S Water meter readings,if (last 2 years usage(gpo): Sump pump(Yes or no) Last date of occupancy: COMMERCIALMMUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): cod Basis of design flow(seatsfpersons/sgft,etc.): Grease trap present(yes or no):_ IndastrW waste holding tank present(yes or no):_ Non-sanitary waste discharged to the Title 5 system(yes or no):— Water meter readings,if available: Last date of occupancylase: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part of the inspection es or no): R yes,v olume _ lions—How was quantity pumped determined? Reason _Se box,soil absorption system _Single cesspool _Overflow cesspool —Ptivy _Shared system(yes or no)(if yes,attach previous inspection records,if arty) _ImmvativeJAlteanative technology.Attach a copy of the comet 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) of information: Were sewage odors detected when arriving'at the site(yes or no): Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: ��t evo iri, Z �- / �Ms /r� /�4 Oa G'G� Owner. Cool Date of Inspection: s?o 0 BUILDMG SEWER(locate on site plan) Depth below grade: Materials of constncction: fuon0 PVC_other(explaink Distance from private water supply well or suction line: Comments(on condition a(joints,venting,evidence of leakage,etc.): SEPTIC TANK: 1/ocate on '_(I site plan) Depth below grade: Material of construction: concrete Tmetal _polyethylene —other(explain) N tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certifir,ate) Dimensions: Sludge depth: i ,, Distance from top of dudge to bottom of outlet tee or baffle: Scam thickness: D _ Distance from top of scam to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee baffle: How were dimensions determined D Ac, Pv c e Commens(on pumping recommendations,inlet and o tee or baffle condition,stnichnW integrity,liquid levels as N v"1 owlet Invert, of l�eetc). �t i`'� � o✓> > � o fl ec // Ape s oN GREASE TRAP:Gocate on site plan) Depth below grade:_ Material of construction:_concrete metal fiberglass_polyethylene_other (expo): Dimensions. Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet in vM evidence of leakage,etc.): Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(contimied) Property Address: Owner: ��/�,-�cp �s �► ��/�j /jam � D d G 6� Date of Inspection: o RJ TIGHT or HOLDING TANK:!(tank must be pumped at time of inVecfionXj=W on site pin) Depth below grade: Material of construction concrete metal fiberglass._polye ftlene other(expLdny Dimes: may. gallons Design Flow. aallans/day Alarm present(yes or noy Alarm level: Alarm in working order(Ves or no): Date of last pumping: Comments(conditiari of alarm and float switches,etc.): DISTRIBUTION SOX: �(if present must be openedxloc ate on site plan) Depth of liquid level above outlet invert: Comments(Wte if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into out of box,etc.): / A i0 P PUMP CHAMBER:"(I on Site plan) Pumps in working order(yes or no): Alarms in working.order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): I Page 9 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1,44 �Owner: C�� Date of Inspection: o A SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: i�,�g S�lam,number:l / leaching chambers,number: VIP,. leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number- . - divetalternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): / 1 S��n .� /,"t✓ i ON i l � Ol i VJ CESSPOOLS: '( l must be _•67�( pumped as part of inspectioaxIocate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer. Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY:�ocate 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.): Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continaedl Property Addrem `T T ✓q 1✓► owner: Date of Inspection: « a QI SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage dam[system including ties to at least two permanent reference Lwdmaft or benchmarks.Locate an weds within 100 feet.Locate where public water supply enters the bm-Wing. I Page 11of11 ~ OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C j� SYSTEM INFORMATION(continue Property Address: Y�1 ✓i / r�� r: Gi n�-o '��� e Owner. Date of b*ec ian; 3v p SITE EXAM Slope Surface water Shallow wells j' Estimated d*(h to water�J feet Please mare.(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 FopertyMbservation hole within ISO feet of SAS) checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) T'6 r' Ac=sed USGS database-explain: You must�describe how you established the high ground water elevation: ` 01 1` BB a d irr�� O p V y � .DpA , ``Y ® 0 (U a,3 l o 'Z= so LO CAT I0 � O i S E W-A G 1 PERMIT N0. VILLAGE P bi INS TA LL E R'S NAME ADDRESS i S UIL R OR OWNER DATE PERMIT ISSUED , DATE COMPLIANCE ISSUED � 7 5�'1 es n la, � �6K �e '�L �-S' ✓� 03nSS1 13NVI1dW03 31V0 L'C)J -1-4 03ASS1 1INV3d 31V0 �U � V3NM0 VO` & ling SSIVQO 3WVN S.0 i1 V SNI 39V11IA 'ON LINN3'41 ISVM3S �11/011V301 ����� � �� ��,. .� ��. ��� ® � r � a �. �►� � 6� �� . ., No..------;.......... Fm3 THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ............I'-- ------i�....OF....... t:� ................................ - - Application for Bhipaual Works Tonstrurtion famit Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal.,- System at: ...........G-E.M.W.J........ .............#...JS.... .................................................................................................. Lot N Tess 05 Add .......................... 0* ....a&,a- -6 0 ...............................RMCLP-6 MM& 'a_Q......... Installer Address Type of Building Size Lot....3�,SQ.!..Sq. feet Dwelling—No. of Bedrooms.............3........................Expansion Attic Garbage Grinder F 16) P4 Other—Type of Building ............................. No. of persons............................ Showers Cafeteria P4Other fixtures ------------------------------------------------------------------------------------------------------------------------------------------------------ Design Flow............6,5.......................gallons per person per day. Total daily flow.........330.....................gallons. 9 Septic Tank-L Liquid`capacity../OOQallons Length................ Width........_...._.. Diameter.._............. Depth......_......._. Disposal Trench—No. .................... Width..._........._._.... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No........./......... Diameter../4!.... ...... Depth belowlet....._ Total leaching area.5Q'.�?.G. ..sq. ft. 0 Dosing tank Other Distribution box ( ) _' .,,V "�­01,.-q. /7- 0-4 Performed I �4 !2_�:n__minutes per inch Depth of Test P .................. Depth to ground water........................ 4 Percolation Test Result ------ ............. Date.._.t4 Z:nZ'911............. 0-s Test Pit No. I.- it.- Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........._..........____ ...� . ......... ................/......... ............. 0 Description o6 Soil..........jd..... .....i w ........... ........./1.......�t.... . U ........................................ ....... . .......... ..............;,VYz .. ........................ U Nature of Repairs or terations—Answer when applicabl ............................................................................................... .................................................................................................................................................................................................. Agreement: 4 The undersigned agrees to. install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE LE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Date -4644-44-1V—A lication Approved BY------ _7.--7.'2.......... Date Application Disapproved for the following reasons:................... ............................................................................................ ......................................................................................................................................................................................................... Date PermitNo......................................................... Issued-. . .....7........ ...............7............. Date (/JI • t 'fir•. t'£.,.:. I r �- No .. Fps...... ...... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HE H . ........... .1.:QQ i(/.y. ...........OF........fit ..... .Applutt#ion f Tar'Uiipus,al Burks Tonstrnrtinn rrmif �Applicaation is t r hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: i. ......' . � ._ ..D_-yi.o.e).----------- ..../.,?.... ........................................... --------...........---------...........__ ... ... .... .. Locatio -Address r Lot o. _. 1....L .` _Sn .......................... '....4 r.., Owne ' ------------------------------ " c7 11�.¢...., r . ..1� .._.. Installer Address Type of Building Size Lot_-__e ?,:., �.Sq. feet Dwelling—No. of Bedrooms.............. ....................... Expansion Attic ( ) Garbage Grinder (4146 Other—Type of Building N of ersons____________________________ Showers a YP g ...................•------_. o. P v ( ) — Cafeteria ( ) dOther fixtures ----..._..•-•-- --•-••••••-•-•••••-._...._....•---•••.--•••...--•••-••-••••••••••••••-•-•-•••-•••..................•----...---•••-----...........---- W Design Flow____.______>5i ......................gallons per person per day. Total daily flow......... Q.....................gallons. WSeptic Tank A Liquid'capacity._/CD allons Length......::...:.... Width................. Diameter................ Depth................ x Disposal Trench—No_ ____________________ Width............ Total Length.................... Total leaching area....................sq. ft. Seepage Pit No.........I_........ Diameter...149.......... Depth below iplet.....__6y�.,... Total leaching area_6;ke?_.sq. ft. z Other Distribution box ( ) Dosing tank( ) © "� + /'' 7 '-' Percolation Test Results Performed b --- .. Date-- �. /"°-* a �• / Y - - -ate(-_ �.---------------- - '�_.fi___.......`�':............. Test Pit No. 1-•+�a•A-..minutes per inch Depth of Test Pit____________________ Depth to ground water........................ LZ4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a t ---------- O Description Soil..-•--• '.ae� .pC �..... F�. �.. , -• .... ': _ ........... -......--•------- y W -••- �! • taa � - UNature of Repairs or Alterations—Answer when applicabl ____________________________________________________________________________________________ Agreement The undersigned agrees to :install the aforedescribd'Individual'Sewage Disposal:System in accordance with the provisions of'TT LI 5 of the State Sanitary Code— The undersigned further agrees not to place'the system in, operation until a Certificate of Compliance has been issued by the board of health. Sag 1e Date Application Approved By....._, ------------------• __ Date Application Disapproved,f or the following.reasons:-; •- ..............----................................................................... --------•---- ----------------------------------- Date PermitNo......................................................... Issued-....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD O HEALTH y ......-..OF.......... iC4!¢<e! ... *:............................... Trr#ifiratr of ToutpliFatta TH by IS TOO CE�jRTIF That the Ind''"dual Sewage Disposal System constructed ( ' or Repaired ( ) ---- Instal at. "- 6�j l�� = 1A - 'JFtd h T. � as been installed m accordance with the p > tons of � � of The State Sanitary Code as described in the application for,Disposal Works Construction Permit N 7 I�._ JAI_________________ dated-..... . -__"_ _�--_�%.' _�_____._ THE ISSUANCE OF THIS. CERTIFICATE SHALT. NOT BE CONSTRUE® ASA GUARANTEE THAT THE SYSTEM WILL:,.FUNCTION SATISFACTORY. ''x S— 7� DATE...... __- Inspector._._,__.. THE COMMONWEALTH OF MASSACHUSETTS BOARD QF HEALTH ,C '... . OF._. ,-:4111±I�-1� r.................................................. No ....... ....... FEE.......< .... Wn rrmit .;.., Permission 15 hereby ranted___ , •� ( . ........... ( - T- --Isposal�SY.... k to Constr t or a air an Indiv�dnal Sevt �e p StreEf PP P •-----------------•••-----••••------------ as shown on the application for Dis osal �L rks Construction P Noy Dated.......................................... DATE---� f -------------•---------__---___.... ` Board Health r g h FORM 1255� HOBBSa& WARREN;.INC., PUBLISHERS SECTION - SEWAGE "' `" - SEPTIC TANK - - "D"kOX - -- LEACH scWur�c TOP OF FDN \ —59} 7-- (MSL) OF 8TO '/2" - WASHED STONEr ^ VC 0.II JV15U1+a t1le d15yZLY)cr ^' )0' aroor,6 (2r- re U P'+ GLnd "woleLc.e Yv/cleav- r�x1A'SF .Ge +"U. ♦ ` \ \ Ct1'x 3 \ _ 7/x8 11-1 •� IN OUT IN 0UI -iN - o_� I; 7Gv? �50_ \ , 3 / G._� ']S n0 74Z(c9 SEPTIC ��. � r L ) \ 1.,9rS ELEV.. -- _ --� TANK l 7�-�B "�• (�� , /`'� `t ,J ELEV. ELEV. `ELEV. l '9 \ ��� 5cgo s.4 x ELEV. ELEV. 6��Jts J4xU QcoT iE : �( G \ OF la'ONE 1 0 n n WASHED STONE TEST HOLE LOG ��sf t t /C`lCLI't� U�//.�✓/'i^s2t7/ - ��Il� {1.l �'` vl�- r ',r ' . 1�,160 "?5:9 TEST BY �q WITNESS ------ ) 1 "F, (S? .! _•' ,,' ; 1--. M ,�� TEST DATE r�//�..?-�!� DESIGN �.. --- . — -- ---BEDROOM HOUSE \ l T.H. # 1 T.H. # 2 ` 1Gf�! 759 v✓ a. FI Fv 6 jI 1 7S' 6' /oc+✓�i DISPOSER DISPOSER 'd _ -- J6X 7 � ice,f I PERC RATE __ _ _ MIN, IN. 4 t 3a i FLOW RATE 33c') (GAL./DAY ) ` - -L� 7 SEPTIC TANK 33v x (l.s1= �- ��ST.. ;- ---_--_ 3 \ �`Zo' _J!7 � % REO'D SEPTIC TANK SIZE 1. ---- 7o'7 - LEACH FACILITY 5 e 78X3 _ V c4c�c' 79� 2 �76r_7 J 9.,? ca! SIDE WALL �a� 9 r��(�"sl = 9�_�4 G/D. ` BOTTOM -- e�'� -'` ( /O ) _ .._ BG.6.. G/D. c � d TOTAL Sze/.USE: ._.___ _ ( 1� ______ LEACHING !(-.I yv2' ��—vc/ASNELz STo r/E )c/. z .RQ_._.WATER ENCOUNTERED -- --- - ---------- - - - ... --- --- , f3.M. n_3� 76_6, NOTES: (UNLESS OTHERWISE NOTED) OF G-13, f/ 1. DATUM (MSL) `. TAKEN FROM ,_____-,_ ..---------- ..._. _QUADRANGLE MAP - '_...•. S 2. MUNICIPAL WATER... -----._._.._.,_ _..AVAILABLE JAmE.ac �,, ' JAMFS 3. PIPE PITCH: 14"PER FOOT ''� W �.r /4 4. DESIGN LOADING FOR ALL.PRECAST UNITS. AASHO - //L' _ AJ $ BOWMAN r )� 5. MIN GROUND COVER OVER ALL SEWAGE FACILITIk'S (1) FT. DIY �w BnVJI>A. - -4--DISTANCE AS CERTIFIED b. PIPF JOINTS SHALL BE MADE WATER TIGHT � � �Ty 24040 7. CONSTRUCTION DETAILS TO BE ACCORDANCE WITH COMM.DI' MASS. O Q�i.f��� /p' .-� l`'f•�s�.��ti'.' e�f, I HEREBY CERTIFY THAT-THE BUILDING SITE PLAN _S7A'fF F.NVIRDNMF.N'1'Ak,CODE TITLE 5 ` /� r : SHOWN ON THIS PLAN IS LOCATED ON THE DNA:- �SU �1Yj{� GROUND AS SHOWN HEREON & THAT IT -_ LOCUS -✓ ' �� - �!�'!(J! �C/I/� I ' � CONFORM TO THE ZONING BY LAWS OF THE TOWN OF REG. rROFF-SSIONAL ENGINEER WHEN CONSTRUCTED DATE _ L qLi /O�" z33 ��k3, /9• - ��I// wI �s REF �.� __.. _ _ down cope engineering PREPARED FOR w CIVIL ENGINEERS LAND SURVEYORS BOARD OF HEALTH 'REG. LANn SURVEYOR f ,! '-,y .ti r� ,., - -- -- •- - (lI.IRS EXISFING) �AF SCALE. . - k RUk'UbLu' v 0 Cl O I PI10 fiL ["IQ IF 'q "f'_ " CONT ; , 1 „ , r ,r � -". -. •-VST �MA Yarmouth & Orleans,MA - -DATE ' I Nomad I