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HomeMy WebLinkAbout0039 HILLIARD'S HAYWAY - Health 39 Hilliard's Hayway W:wB-arnstab[a- P.; A`f=" 136 048 �I E r /36a -0q9 c Commonwealth of Massachusetts Title 5 Official Inspection Form Cn Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 39 Hilliards Hayway Property Address Jim and Sue Kelleher Owner Owner's Name r _ information is required for every arnstable Ma 02630 9/11/18 page. City/Town State Zip Code Date of Inspection =1", LF. Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. Inspector Information 51 133q_�- filling out forms on the computer, use only tie tab Michael DiBuono key to move your Name of Inspector cursor-do not DiBuono Sewer And Drain use the return Company Name key. 35 Content Lane L Company Address Cotuit Ma 02635 fA Citylrown State Zip Code 508-364-9587 S113522 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails ,r 9/12/18 nspector'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 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 form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18 Commonwealth of Massachusetts u Title 5 Official Inspection Form to Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 39 Hilliards Hayway Property Address Jim and Sue Kelleher Owner Owner's Name information is required for every Barnstable Ma 02630 9/11/18 page. Citylrown State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: System contains a 1500 Gallon septic tank as well as a concrete distribution box and 3 500 Gallon chambers in stone 2) 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): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 I c� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Hilliards Hayway Property Address Jim and Sue Kelleher Owner Owner's Name information is required.or every Barnstable Ma 02630 9/11/18 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ 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): 3) 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. a. System will pass unless Board of Health determines in accordance with 310 CMR f 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form4 Al m Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Hilliards Hayway Property Address Jim and Sue Kelleher Ownfoner Owner's Name requir required is every Barnstable re wired for eve Ma 02630 9/11/18 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ 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 b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: i i 4) 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form -Not for Voluntary Assessments !% 39 Hilliards Hayway Property Address Jim and Sue Kelleher Owner Owner's Name information is required for every Barnstable Ma 02630 9/11/18 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® 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 Y2 day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply 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 2000 gpd- 10,000 gpd. ❑ ® 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. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section CA. 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 t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form to Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Hilliards Hayway Property Address Jim and Sue Kelleher Owner Owner's Name information is required for every Barnstable Ma 02630 9/11/18 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes"to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate "yes" or"no"for each of the following for all inspections: 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)] t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18 c Commonwealth of Massachusetts ,�p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments v% 39 Hilliards Hayway Property Address Jim and Sue Kelleher Owner Owner's Name information is required for every Barnstable Ma 02630 9/11/18 page. Cityrrown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ❑ No Water meter readings, if available last 2 ears usage d 178 9 ( Y 9 (gP ))� Detail: Sump pump? ❑ Yes ❑ No Last date of occupancy: Date t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form ja Subsurface Sewage Disposal System Form -Not for Voluntary Assessments V% 39 Hilliards Hayway Property Address Jim and Sue Kelleher Owner Owner's Name information is required for every Barnstable Ma 02630 9/11/18 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 2. 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 Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Pumped 2015 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: l5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Fl Subsurface Sewage Disposal System Form - Not for Voluntary Assessments V 39 Hilliards Hayway Property Address Jim and Sue Kelleher Owner Owner's Name information is required for every Barnstable Ma 02630 9/11/18 page. City(rown State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: 10/26/01 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. 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.): System is vented at the roof line t5insp.doc rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �v 39 Hilliards Hayway Property Address Jim and Sue Kelleher Owner Owner's Name information is required for every Barnstable Ma 02630 9/11/18 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 1.5 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) 1500 If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: 3 Distance from top of sludge to bottom of outlet tee or baffle 24" Scum thickness 3" 411 Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 30" How were dimensions determined? Tape Measure 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 is sound with no leaks j. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 I Z Commonwealth of Massachusetts -, Title 5 Official Inspection Form F Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Hilliards Hayway Property Address Jim and Sue Kelleher Owner Owner's Name information every is required fcr Barnstable Ma 02630 9/11/18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. 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 Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. 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 t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 Commonwealth of Massachusetts 1. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 39 Hilliards Hayway Property Address Jim and Sue Kelleher Owner Owner's Name information is required for every Barnstable Ma 02630 9/11/18 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) 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 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Level with no sign of carry over 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.): l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 cam, Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Hilliards Hayway Property Address Jim and Sue Kelleher Owner Owner's Name information is required for every Barnstable Ma 02630 9/11/18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ® leaching chambers number: 3 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form l� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 39 Hilliards Hayway Property Address Jim and Sue Kelleher Owner Owner's Name information is Barnstable Ma 02630 9/11/18 required for every page.e. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): No ponding or break out 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer ,Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): r 'I l5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18 I Commonwealth of Massachusetts l Title 5 Official Inspection Form la Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Hilliards Hayway Property Address Jim and Sue Kelleher Owner Owner's Name information is required fog every Barnstable Ma 02630 9/11/18 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) 13. 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.): I I� t5insp.doc rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 C Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Hilliards Hayway Property Address Jim and Sue Kelleher Owner Owner's Name information is required for every Barnstable Ma 02630 9/11/18 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 14. 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 t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 9/11/2018 Assessing As-Built Cards TOWN OF BARNSTABLE V LOCATION 39 SEWAGE x 240ei -Gs 3 Z VILLAGE <, ,vclr NNGIC W gAQ/YASSESSOR'S MA &LOT 11(JCY� INSTALLER'S NAME&PHONE NO. SaN i Ufa - O/G SEPTIC TANK CAPACITY f= • LEACHING FACILITY:(type)3_✓` 4�/Aaikb4K (size)32"X- 31X Z_ NO.Op BEDROOMS N BUILDER OR OWNER C44' PERMrrDATE: ?—2 b O/ COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility �` Feet Private Water Supply Well and Leaching Facility (If any wells exist r on site or within 200 feet of leaching facility) t5 0 Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) /.SQ Feet Furnished by i 116 . 31 5 • o D d http://www.tcwnofbamstable.us/Assessing/HMdisplay.asp?mappar-1 36048&seq=1 1/2 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 39 Hilliards Hayway Property Address Jim and Sue Kelleher Owner Owner's Name information is required for every Barnstable Ma 02630 9/11/18 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 7+ 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: 9/2/01 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Test hole data on plan Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form P �a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 39 Hilliards Hayway Property Address Jim and Sue Kelleher Owner Owner's Name information is Barnstable Ma 02630 9/11/18 required for every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ❑ A. Inspector Information: Complete all fields in this section. ❑ B. Certification: Signed & Dated and 1, 2, 3, or checked ❑ C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist) completed ❑ D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 40 Commonwealth of Massachusetts Title 5 Official Inspection Form 19 I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 39 Hilliard Hayway Property Address Richard Weiler Owner Owner's Name informations required for West Barnstable MA 02668 06/05/10 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Important: A. General Information When filling out forms on the / computer, use 1. Inspector: Ilin� only the tab key to move your Michael Kellett t' cursor-do not Name of Inspector At- use the return key. Aardvark Environmental Inspection Company Name Q1 P.O. Box 896 Company Address PCitEast Dennis MA 02641 7Ed�" y/Town State Zip Code 508-385-7608 S13742 Telephone Number License Number B. Certification 1 certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to.Section 15.U0 pf Title 5 (310 CMR 15.000).The system: - ! ® Passes ❑ Conditionally Passes ❑ Fails, _w CIO ❑ Needs Further Evaluation by the Local Approving Authority5 � � E T t c�art�` 06/05/10 Inspector's Signature Date ? The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ""This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same ordifferent conditions of use. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Hilliard Hayway Property Address Richard Weiler Owner Owner's Name information is required for West Barnstable MA 02668 06/05/10 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Answer yes, no or not determined (Y, N, ND) in the ❑ for the following statements. If"not determined," please explain. ❑ The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Hilliard Hayway Property Address Richard Weiler Owner Owner's Name information is West Barnstable MA 02668 06/05/10 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced R. obstruction is removed ND Explain: C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ 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. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 39 Hilliard Hayway Property Address Richard Weiler Owner Owner's Name information is required for West Barnstable MA 02668 06/05/10 i every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, perfoaned 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 ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 'h day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M , 39 Hilliard Hayway Property Address Richard Weiler Owner Owner's Name information is West Barnstable MA 02668 06/05/10 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cunt.): Yes No ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 1 0,000g pd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 39 Hilliard Hayway Property Address Richard Weiler Owner Owner's Name information is West Barnstable MA 02668 06/05/10 required for every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® 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)] Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 39 Hilliard Hayway Property Address Richard Weiler Owner Owner's Name information is required for West Barnstable MA 02668 06/05/10 every page. Cityfrown State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 2 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)): Sump pump? ❑ Yes ® No Last date of occupancy: current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Hilliard Hayway Property Address Richard Weiler Owner Owner's Name information is required for West Barnstable MA 02668 06/05/10 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: 11/03 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: 10/26/01 per BOH Were sewage odors detected when arriving at the site? ❑ Yes ® No Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 39 Hilliard Hayway Property Address Richard Weiler Owner Owner's Name information is required for West Barnstable MA 02668 06/05/10 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 2.2 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.): Septic Tank(locate on site plan): Depth below grade: 0.5 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 gal Sludge depth: 4" Distance from top of sludge to bottom of outlet tee or baffle 28" Scum thickness 2" 7" Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 16" How were dimensions determined? measured � Commonwealth of Massachusetts v r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 9� 39 Hilliard Hayway Property Address Richard Weiler Owner Owner's Name information is required for West Barnstable MA 02668 06/05/10 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): The tank was sound and tight with tees in place and liquid at outlet invert. 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 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): Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 39 Hilliard Hayway Property Address Richard Weiler Owner Owner's Name information is West Barnstable MA 02668 06/05/10 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank (cont.) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert even 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.): The box was level and tight with no sign of carryover. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes 0 No Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 39 Hilliard Hayway Property Address Richard Weiler Owner Owner's Name information is required for West Barnstable MA 02668 06/05/10 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ® leaching chambers number: 3 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): This System has three chambers surrounded by threefeet of stone.The stone were dry with no sign of ponding or failure. Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Hilliard Hayway Property Address Richard Weiler Owner Owner's Name information is required for West Barnstable MA 02668 06/05/10 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Hilliard Haywa Property Address Richard Weiler Owner Owner's Name information is West Barnstable MA 02668 06/05/10 required for C (town state Zip Code Date of Inspection every page. D. System Information (cunt.) Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal l wells within 1 0 feet. ties to at least two permanent reference landmarks Locate where public water supply enters the building. `l b �6 ro� Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Foam -Not for Voluntary Assessments 39 Hilliard Hayway Property Address Richard Weiler Owner Owner's Name information is required for West Barnstable MA 02668 06/05/10 every page. City/Town State Zip Code Date of Inspection D. System Information cont. y (cont.) Site Exam: ® Check Slope ❑ Surface water ® Check ce0ar ❑ Shallow wells Estimated depth to high ground water: 10+ feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: Date 01 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: Engineering plan show mottling atelevation 9.15 and bottom of leaching at14.36. 09/13/2007 THU 14: 57 FAX 5083627103 Barnstable CTY HealthLab -a-- Barnstable Health 21 )01/003 I, -v r CERT1��tl.L�1 ®F ANALYSIS�1� Pad< 1 c �,... „ . �t Barnstable County Health Laboratory ` .,�`= j� P'.eP ort Prepared For: Report Datcd: 9/13/2007 Sally Desmond Desmond Well Drilling Order No.: G0743365 P O Box 2783 Orleans, MA 02653 0743365-01 Description: Water-Drinking Water Sample if: Sampling Location: 39 Hilliards Hay Way West Barnstable,MA Collected: 9/I1/2007 ( Coliac+,d !:,v: Customer Received: 9/11,'2007 I '�tDJCr1't't2e ITEM RESULT UNITS RL MCL Method# Tested Nitrate as Nitrogen 0.27 mg/L 0.10 10 EPA 300.0 9/11/2007 l mg/L 0.10 1.3 SM3111B 9/12/2007 C"gPer ND g/1 lrol ND mg/L 0.10 0.3 SM3111B 9/12/2007 Sodium 9.8 mg/L LO 20 SM3111B 9/12/2007 "iV A OJ1ifOr1Y1 Absent P/A 0 0 SM9223 9/11/2007 i C ondUCtance 110 umohs/cm 2.0 EPA 120.1 9/11/2007 f PEE 6.7 pH-units 0 SM 4500 H-B 9/11/2007 I Water sample meets the recommended limits for drinking water of all lite above tested parameters. j 7 � ; Approved By. _� I (Lab rector) i 167 { I I) 1 1 i ND=None Detected RL = Reporting Limit MCL=Maximum Contaminant Level Superior Court House, PO.Box 427, Barnstable, MA 02.630 Ph: 508-375-6605 L 09/13/2007 THU 14: 58 FAX 5083627103 Barnstable CTY HealthLab ---{ Barnstable Health 0003/003 Y CERTI]FICATE OF ANALYSIS Pal, 2 Barnstable County Health ]Laboratory .� F j wwi: Prepared For: Report Dated: 9/13/2007 Saily Desmond t+ Desmond Well Drilling Order No.: G0743365 P 0 Box 2783 Orleans, MA 02653 t 1.• - 1 Laboratoti ID#: 0743365-01 Description: Water-Drinking Water Sample 4: Sampling Location: 39 Hilliards Hay Way West Barnstable,MA Collected: 9/11/2007 Collected lty: Customer Received: 911 L'2007 "A 524:.2 r Volatile Organics by GUMS TSENI RESULT UNITS RL MCL Method# Analyst Tested mote C.arbort tetrachloride ND ug/L 0.50 5.0 EPA 524.2 yn 9/11/2007 1 l ( 1:1orobenzene ND ug/L 0.50 100 EPA 524.2 yn 9/11/2007 C'hloroethane ND ug/L 0.50 EPA 524.2 yn 9/11/2007 Chloroform ND ug/L 0.50 80 EPA 524.2 yn 9/11/2007 cis-1,2-Dichloroethene ND ug/L 0.50 70 EPA 524.2 yn 9/11/2007 s cis-1,3-Dichloropropene ND ug/L 0.50 EPA 524.2 yn 9/I1/2007 s Di bre mochlorom ethane ND ug/L 0.50 EPA 524.2 yn 9/11/2007 ! J is Dbromomethane ND ug/L 0.50 EPA 524.2 yn 9I11/2007 ! Ethyibenzene ND ug/L 0.50 700 EPA 524.2 yn 9/11/2007 l Fiexachlorobutadien.- ND ug/L 0.50 EPA 524.2 yn 9/11/2007 Isopro�ylbenzelnt9 ND ug/L 0.50 EPA 524.2 yn 9/11/2007 1 M1!thlllene chloride ND ug/L 0.50 5.0 EPA 524.2 yn 9/11/2007 i .. l Nfethyl-ter?-butyl ether ND ug/L 0.50 EPA 524.2 yn 9/11/2007 ' r:lapi thalene ND ug/L 0.50 EPA 524.2 yn 9/11/2007 r:-t3•ut,{Ibenzene ND ug/L 0.50 EPA 524.2 yn 9/11/2007 n-Propylbenzene ND ug/L 0.50 EPA 524.2 yn 9/11/2007 p-isopropyltoluene ND ug/L 0.50 EPA 524.2 yn 9/11/2007 u 0.50 EPA 524.2 n 9/1 112007 l se:,-}?utyloei�zer..e ND �- y i f Styrer;e ND ug/L 0.50 100 EPA 524.2 yn 9/11/2007 T u 0.50 EPA 524.2 n 9/11/2007 terF-�-+�ltylbenzLne 1�D >� Y ; Tetrachloroethene ND uafL, 0.50 5.0 EPA 524.2 yn 9/11/2007 Toluene ND ug/L 0.50 1000 EPA 524.2 yn 9/11/2007 Total xvlenes ND ug/L 0.50 10000 EPA 524.2 yn 9/11/2007 i trans-1,2-Dichloroethene ND ug/L 0.50 100 EPA 524.2 yn 9/11/2007 trans-,1,3-Dichloropropene ND ug/L 0.50 EPA 524.2 yn 9/11/2007 Tri.ch'oroethene ND ug/L 0.50 5.0 EPA 524.2 yn 9/11/2007 Tri.ch:orofluoromethane ND ug/L 0.50 EPA 524.2 yn 9/11/2007 Faster sample meets the recommended limits for drinking water of all the above tested parameters. j Approved By: 77 (Lab ector)i ND=None Detected RL = Reporting Limit MCL=Maximum Contaminant Leve Superior Court House, PO.Box 427, Barnstable, MA 02630 Ph: 508-375-6605 1 I i 09/13/2007 THU 14: 58 FAX 5083627103 Barnstable CTY HealthLab Barnstable Health �1002/003 r I: -Ot_.n^p . CERTIFICATE OF ANALYSIS MiBarnstable County Health Laboratory i actaLSJ ]l<'ryort Prepared For: Report Dated: 9/13/2007 &,ily Desmond Dl;smond Well Drilling Order No.: G0743365 P O Box 2783 Orleans, MA 02653 La oratory ><D : 0743365-01 Description: Water-Drinking Water sample;':'. Sampling Location: 39 Hilliards Hay Way West Barnstable,MA Collected: 9/11/2007 Couec;ted br: Customer Received: 9/11;2007 EPA 524.2 - Volatile Organics by GC/M,S t ITG1Yi RESULT UNITS RL MCL Method# Analyst Tested Note { Dichlorodifluoromethane ND ug/L 0.50 EPA 524.2 yn 9/11/2007 Chloromethane ND ug/L 0.50 EPA 524.2 yn 9/11/2007 1 Vinyl era pride: ND ug/L 0.50 2.0 EPA 524.2 yn 9/11/2007 1 B.omonetharte ND ug/L 0.50 EPA 524.2 yn 9/11/2007 1,1,1,2-Tetrachloroethane ND ug/L 0.50 EPA 524.2 yn 9/11/2007 1,1,1-Trichloroethane ND ug/L 0.50 200 EPA 524.2 yn 9/I1/2007 i,1,2.2-Tetrachloroethane ND ug/L 0.50 EPA 524.2 yn 9/11/2007 1_,1,2-Trichloroethane ND ug/L 0.50 5.0 EPA 524.2 yn 9/11/2007 . 1,1-Dichloroethz.ne ND ug/L 0.50 EPA 524.2 yn 9/11/2007 l,1-Dichloroethe:ne ND ug/L 0.50 7.0 EPA 524.2 yn 9/11/2007 1,1-L4it hloropropene ND ug/L 0.50 EPA 524.2 yn 9/11/2007 1,2,3-Trichlorobenzene ND ug/L, 0.50 EPA 524.2 yn 9/11/2007 1 i,2,3-'frict�loropropane ND ug/L, 0.50 EPA 524.2 yn 9I11/2007 i4-Trichlorobenzene ND ug/L 0.50 70 EPA 524.2 yn 9/11/2007 1 1,2,4-Trimethvlbenzene ND ug/L 0.50 EPA 524.2 yn 9/11/2007 1,"-Di'�romo-3-chloropropane ND ug/L. 0.50 EPA 524.2 yn 9/11/2007 i l,f.-Di�eomoethane(EDB) ND ug/L 0,50 EPA 524.2 yn 9/11/2007 1,2-Dichioroben ,ene ND ug/L 0.50 600 EPA 524.2 yn 9/11/2007 i 42-Dichloroethane ND ug/L 0.50 5.0 EPA 524.2 yn 9/11/2007 1,::.-Dichloropropane ND uP� 0.50 EPA 524.2 yn 9/11/2007 � I ' 1,3,5-Trimethylbenzene .ND ug/L 0.50 EPA 524.2 yn 9/11/2007 1,3-D-.chlorobenzene ND ug/L 0.50 EPA524.2 yn 9/11/2007 I,3 r)ichloropropane ND ug/L 0.50 EPA 524.2 yn 9/11/2007 ug/L 0.50 5.0 EPA 524.2 yn 9/11/2007 1,4•-Dichlerober:zene ND 2,-:-Uichforopropane ND ug/L 0.50 EPA 524.2 yn 9/11/2007 ?-Chl:orotoluene ND ug/L 0.50 EPA 524.2 yn 9/11/2007 I.-Chlorotoluene ND ug/L 0.50 EPA 524.2 yn 9/11/2007 ; Benzene ND ug/L 0.50 5.0 EPA 524.2 yn 9/11/2007 Brorr,obenzene ND ug/L 0.50 EPA 524.2 yn 9/11/2007 BrOTnochloromethane ND ug/L 0.50 EPA 524.2 yn 9/11/2007 Bromodichloromethane ND ug/L 0.50 EPA 524.2 yn 9/11/2007 Bromoform ND ug/L 0.50 EPA 524.2 yn 9/11/2007 ND=None Detected RL = Reporting Limit MCL=Maximum Contaminant Level Superior Court House, PO.Box 427, Barnstable, MA 02630 Ph: 508-375-6605 l I t �7J! - ---- No. ---------- Fee---- -- --- - BOARD OF HEALTH TOWN OF BARNSTABLE ZippCicat ion-for Welt_Con5truct ion i3ermit Application is hereby made for a permit to Construct ( ), Alter ( `'), or Repair ( )an individual Well at: c N0.` otm— AV o' �S V V_— — —--_ --1�G:> - - U&ationddress -- Assessors Map and Parcel Owner__—_--_ l10`IJ A CL 0.CY\S�Q1C_ 02( g ddressJ 1,,'�— P.� l�vX 2='i$ Oc1 �S YYY-� 02653 Installer — Drillol Address Type of Building Dwelling ------------------------._____ Other - Type of Building-=---__---_____ No. of Persons-------------_-__--- T e of Well 4 SCk\ND PVC' _-___- Ca acit Purpose of Well_-Dd ` '-=-----_ ----�_-- — Agreement: 'he undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation - The undersigned further agrees not to place the well in operation until a Certificate .of Compliance has been issued by the Board of�H�ealth. Signed UI-il. - -- — -4 �� ---- d Application Approved By I dat Application Disapproved for the following reaso ---------------__--____ ___ _____ O date 17 Permit No. --- - Issued 310 late BOARD OF HEALTH TOWN OF BARNSTABLE Certificate ®f Compliance THIS IS TO CERTIFY, That the Individual Well Constructed X, Altered ( ), or Repaired ( ) by ----------------- - --- -- ---___ -- Installer at has been installed in accordance with the roof the Town Barnstable Board of Health Private We Protection p n e Il Regulation as described in the application for Well Construction Permit No. -------.-•-------Dated----------.-- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE —_ Inspector------- -- - ------------ No.--- - . - Fee----;-��.- ---- BOARD OF HEALTH TOWN OF BARNSTABLE - N R Zipplication-for Vell CootructionVrrmit ' Application is hereby made for a permit to Construct (�1), Alter ( ), or Repair ( )an individual Well at: Location —�ddress _ — Assessors Map and Parcel � a ——__ Owner J Address 0265.3------------------- ----- ------------- Installer — Driller Address Type of Building / Dwelling --/ --- - - - --- - , Other - Type of Building--=----------------- No. of Persons---------------------------------- Ty pe of Well ---_—_ P Y---- - - --— ---- ---- f F Purpose of Well---DOrnR Agreement: Tne undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation - The undersigned further agrees not to place the well in operation until a Certificate .of Compliance has been issued by the Board of Health. 77 Signed — ^ - -- A11- H'�--- •� 414da, Application Approved By 17 &— �/ datl f� �. �s Application Disapproved for the following i S* , �^�., ------- �, ----�. -------�—----- - -------- --------------date---:�-- Permit No. '� —� Issued-- _ __----- -- r' date --------------------------------------- t --- —.--------_-----..---_-----------_-------------------- BOARD OF�HEALTH TOWN OF( BARNSTABLE ' Certificate Of Compliance THIS IS TO CERTIFY, That the Individual Well Constructed 06, Altered ( ), or Repaired ( ) Y- - - --� ! --- - - -- -------- - aller 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 SATISFACTORY. DATE----- __— -- - — - Inspector-- - -------------- - --.��---------- ----------------------\-------------------------------=--------------------------- BOARD OF HEALTH TOWN OF BARNSTABLE Ietl Con5truct ion Permit NO. D� Fee- . ------_--_ Permission is hereby granted - �" -�L-C✓-�`��------------- to Construct ( ), Alter ( ), or Repair ( ) an Individual Well at: street as shown on the application for ell Construction Permit r x —r `/"�i No. � � � ---------- Dated--�- ��------------------------------------- DATE - ��- -r n — -- Board of Health — l �/ t do r Massachusetts Department of Conservation and Recreation Massach+.sefu Office of Water Resources deft MQWF Well Completion Report 19-SEP-07 11:10:22 ` WELL LOCATION 250569 GPS North: 410 43.812' GPS West: 700 23.268' Address: 39, Hillard's Hay Way Property Owner/Client: Richard Weiler Subdivision Name: Mailing Address: 39 Hillard's Hay Way Vl 25k City/Town:Barnstable City/Town, State:Barnstable MA Assessors Map: Assessors Lot #: Permit Number:W2007-011 Board of Health permit obtained: Y Date Issued: 04/23/2007 Work Performed Proposed use Drilling Method Overburden Drilling Method Bedrock New Well Domestic Auger CASING From (ft) To (ft) Type Thickness Diameter .00 -27.00 PVC Schedule 40 4.00 SCREEN From (ft) To (ft) Type Slot Size Diameter -27.00 -31.00 Stainless Steel Well .010 4.00 Point WELL SEAL / FILTER PACK / ABANDONMENT MATERIAL From (ft) To (ft) Material Description Purpose WELL TEST DATA (ALL SECTIONS MANDATORY FOR PRODUCTION WELLS) Date Method Yield Time Pumped Pumping Level Time to Recover Recovery (GPM) (hrs & min) (Ft. BGS) (Hrs & Min) (Ft. BGS) 09,111/2007 Constant Rate Pump 20.0000 01:00 18.0000 00:01 4 STATIC WATER LEVEL (ALL WELLS) PERMANENT PUMP (IF AVAILABLE) Date Depth Below Ground Pump Description: Measured Surface (ft) Type: Intake Depth: 09/11/2007 4 Nominal Pump Capacity: Horsepower: WELL DRILLER'S STATEMENT ADDITIONAL WELL INFORMATION Driller: Patrick Desmond Developed:: Yes Fracture Enhancement:No Supervisor: Patrick Desmond Rig #: 36 Disinfected:Yes Well Seal Type:None Firm: Desmond Well Drilling Inc. Total Well Depth: 31.000 Depth to Bedrock: Registration #: 877 Date Complete:09/11/2007 Comments: _OVERBURDEN From To Description Color Comment Water Loss/Add Drill Drill (ft) (ft) Zone of Fluid Stem Drop Rate .00 15.00 Clay Light Gray No N/A 15.00 31.00 Fine to Coarse Sand Brown Yes N/A BEDROCK From To Code Comment Water Drill Extra Drill Rust Loss/ # of (ft) (ft) Zone Stem Large Rate Stain Add of Frac Droo per ft 1/1 - u+G ti °E k�r} CERTIFICATE OF ANALYSIS Page: 1 Barnstable County Health Laboratory 9 , � ncHus�� Report ,Prepared For: Report Dated: 9/13/2007 Sally Desmond Desmond Well Drilling Order No.: G0743365 P O Box 2783 Orleans, MA 02653 Laboratory ID#: 0743365-01 Description: Water-Drinking Water Sample#: Sampling Location: 39 Hilliards Hay Way West Barnstable,MA Collected: 9/11/2007 Collected by: Customer Received: 9/11/2007 Routine ITEM RESULT UNITS RL MCL Method# Tested Nitrate as Nitrogen 0.27 mg/L 0.10 10 EPA 300.0 9/11/2007 Copper Nil mg/L 0.10 1.3 SM 3!!:B 9/!2/2007 Iron ND mg/L 0.10 0.3 SM 3111B 9/12/2007 Sodium 9.8 mg/L 1.0 20 SM 3111B 9/12/2007 Total Coliform Absent P/A 0 0 SM9223 9/11/2007 Conductance 110 umohs/cm 2.0 EPA 120.1 9/11/2007 pH 6.7 pH-units 0 SM 4500 H-B 9/11/2007 Water,sample meets the recommended limits for drinking water of all the above tested parameters. I Approved By. (Lab vector) 9 /3 �b7 �a Z _ J.1 150 ND=None Detected RL = Reporting Limit MCL=Maximum Contaminant Level p g Superior Court House, PO. Box 427, Barnstable, MA 02630 Ph: 508-375-6605 °F CERTIFICATE OF ANALYSIS Page: 1 Barnstable Count Health Laboratory Y Y Report Prepared For: Report Dated: 9/13/2007 Sally Desmond Desmond Well Drilling Order No.: G0743365 P O Box 2783 Orleans, MA 02653 Laboratory 1fD#: 0743365-01 Description: Water-Drinking Water Sample#: Sampling Location: 39 Hilliards Hay Way West Barnstable,MA Collected: 9/11/2007 Collected by: Customer Received: 9/11/2007 EPA 524.2 - Volatile Organics by GUMS ITEM RESULT UNITS RL MCL Method# Analyst Tested Note Dichlorodifluoromethane ND ug/1. 0.50 EPA 524.2 yn 9/11/2007 Chloromethane ND ug/L 0.50 EPA 524.2 yr. 9/11/2007 Vinyl chloride ND ug/L 0.50 2.0 EPA 524.2 yn 9/11/2007 Bromomethane ND ug/L 0.50 EPA 524.2 yn 9/11/2007 1,1,1,2-Tetrachloroethane ND ug/L 0.50 EPA 524.2 yn 9/11/2007 1,1,1-Trichloroethane ND ug/L 0.50 200 EPA 524.2 yn 9/11/2007 1,1,2,2-Tetrachloroethane ND ug/L 0.50 EPA 524.2 yn 9/11/2007 1,1,2-Trichloroethane ND ug/L 0.50 5.0 EPA 524.2 yn 9/11/2007 1,1-Dichloroethane ND ug/L 0.50 EPA 524.2 yn 9/11/2007 1,1-Dichloroethene ND ug/L 0.50 7.0 EPA 524.2 yn 9/11/2007 ],I-Dichloropropane ND ug/L 0.50 EPA 524.2 yn 9/11/2007 1,2,3-Trichlorobenzene ND ug/L 0.50 EPA 524.2 yn 9/11/2007 1,2,3-Trichloropropane ND ug/L 0.50 EPA 524.2 yn 9/11/2007 1,2,4-Trichlorobenzene ND ug/L 0.50 70 EPA 524.2 yn 9/11/2007 1,2,4-Trimethylbenzene ND ug/L 0.50 EPA 524.2 yn 9/11/2007 1,2-Dibromo-3-chloropropane ND ug/L 0.50 EPA 524.2 yn 9/11/2007 1,2-Dibromoethane(EDB) ND ug/L 0.50 EPA 524.2 yn 9/11/2007 1,2-Dichlorobenzene ND ug/L 0.50 600 EPA 524.2 yn 9/11/2007 1,2-Dichloroethane ND ug/L 0.50 5.0 EPA 524.2 yn 9/11/2007 1,2-Dichloropropane ND ug/L 0.50 EPA 524.2 yn 9/11/2007 1,3,5-Trimethylbenzene ND ug/L 0.50 EPA 524.2 yn 9/11/2007 1,3-Dichlorobenzene ND ug/L 0.50 EPA 524.2 yn 9/11/2007 1,3-Dichloropropane ND ug/L 0.50 EPA 524.2 yn 9/11/2007 1,4-Dichlorobenzene ND ug/L 0.50 5.0 EPA 524.2 yn 9/11/2007 2,2-Dichloropropane ND ug/L 0.50 EPA 524.2 yn 9/11/2007 2-Chlorotoluene ND ug/L 0.50 EPA 524.2 yn 9/11/2007 4-Chlorotoluene ND ug/L 0.50 EPA 524.2 yn 9/11/2007 Benzene ND ug/L 0.50 5.0 EPA 524.2 yn 9/11/2007 Bromobanzene ND ug/L 0.50 EPA 524.2 yn 9/11/2007 Bromochloromethane ND ug/L 0.50 EPA 524.2 yn 9/11/2007 Bromodichloromethane ND ug/L 0.50 EPA 524.2 yn 9/11/2007 Bromoform ND uggL 0.50 EPA 524.2 yn 9/11/2007 ND=None Detected RL = Reporting Limit MCL=Maximum Contaminant Level Superior Court House, PO.Box 427, Barnstable, MA 02630 Ph: 508-375-6605 f u CERTIFICATE OF ANALYSIS Page: 2 Barnstable County Health Laboratory Report Prepared For: Report Dated: 9/13/2007 Sally Desmond Desmond Well Drilling Order No.: G0743365 P O Box 2783 Orleans, MA 02653 Laboratory ID #: 0743365-01 Description: Water-Drinking Water Sample#: Sampling Location: 39 Hilliards Hay Way West Barnstable,MA Collected: 9/11/2007 Collected by: Customer Received: 9/11/2007 EPA 524.2- Volatile Organics by GC/MS ITEM RESULT UNITS RL MCL Method# Analyst Tested Note Carbon tetrachloride ND ug/L 0.50 5.0 EPA 524.2 yn 9/11/2007 Chlorobenzene ND ug/L 0.50 100 EPA 524.2 yn 9/1 11200 7 Chloroethane ND ug/L 0.50 EPA 524.2 yn 9/11/2007 Chloroform ND ug/L 0.50 80 EPA 524.2 yn 9/11/2007 cis-1,2-Dichloroethene ND ug/L 0.50 70 EPA 524.2 yn 9/11/2007 cis-1,3-Dichloropropene ND ug/L 0.50 EPA 524.2 yn 9/11/2007 Dibrom och I orom ethane ND ug/L 0.50 EPA 524.2 yn 9/11/2007 Dibromomethane ND ug/L 0.50 EPA 524.2 yn 9/11/2007 Ethylbenzene ND ug/L 0.50 700 EPA 524.2 yn 9/11/2007 Hexachlorobutadiene ND ug/L 0.50 EPA 524.2 yn 9/11/2007 Isopropylbenzene ND ug/L 0.50 EPA 524.2 yn 9/11/2007 Methylene chloride ND ug/L 0.50 5.0 EPA 524.2 yn 9/11/2007 M ethyl-tert-buty I ether ND ug/L 0.50 EPA 524.2 yn 9/11/2007 Naphthalene ND ug/L 0.50 EPA 524.2 yn 9/11/2007 n-Butylbenzene ND ug/L 0.50 EPA 524.2 yn 9/11/2007 n-Propylbenzene ND ug/L 0.50 EPA 524.2 yn 9/11/2007 p-Isopropyltoluene ND ug/L 0.50 EPA 524.2 yn 9/11/2007 sec-Butylbenzene ND ug/L 0.50 EPA 524.2 yn 9/11/2007 Styrene ND ug/L 0.50 100 EPA 524.2 yn 9/11/2007 tert-Butylbenzene ND ug/L 0.50 EPA 524.2 yn 9/11/2007 Tetrachloroethene ND ug/L 0.50 5.0 EPA 524.2 yn 9/11/2007 Toluene ND ug/L 0.50 1000 EPA 524.2 yn 9/11/2007 Total xylenes ND ug/L 0.50 10000 EPA 524.2 yn 9/11/2007 trans-1,2-Dichloroethene ND ug/L 0.50 100 EPA 524.2 yn 9/11/2007 trans-1,3-Dichloropropene ND ug/L 0.50 EPA 524.2 yn 9/11/2007 Trichloroethene ND ug/L 0.50 5.0 EPA 524.2 yn 9/11/2007 Trichlorofluoromethane ND ug/L 0.50 EPA 524.2 yn 9/11/2007 Water sample meets the recommended limits for drinking water of all the above tested parameters. Approved By: (Lab ector)i ND=None Detected RL = Reporting Limit MCL=Maximum Contaminant Leve Superior Court House, PO. Box 427, Barnstable, MA 02630 Ph: 508-375-6605 COMMONWEALTH OF MASSACHUSETTS Z w EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS r e DEPARTMENT OF ENVIRONMENTAL PROTECTION e non ye y� l�(,0 ASSESSORS MAP NO' L TITLE 5 PARCEL NO* OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 39 Hiliards Hay Way West Barnstable MA 02668 Owner's Name: Richard Trifone Owner's Address: Same Date of inspection: June 9,2004 RECEIVED Name of Inspector: PATRICK M.O'CONNELL JUL 0 7 2004 Company Name: SEPTIC INSPECTION SERVICES CO. TOWN Mailing Address: 189 CAMMETT ROAD H OLTH RNS'Nt`E D MARSTONS MILLS MA 2 0 648 EP T. Telephone Number: 508-428-1779 CERTIFICATION STATEMENT I certify that 1 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 DE�'llltllfl/ approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: %kOFMgJ XX__Passes .Conditionally Passes TRI • cGn Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature Date: _6/9/2004l�[1Ft :�OQ��`�� 6,5INSPEG JJJJf1Il l 1t11111�� . The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments: Observed no standing water in leaching chambers. ""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 6/15/2000 page I Page 2 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 39 Hillards Hay Way,West Barnstable Owner: Richard Trifone Date of Inspection: June 9,2004 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: _XX_ 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. Answer yes, no or not determined(Y,N,ND) in the for the following statements. if"not determined" please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced _ obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): _+broken pipe(s)are replaced obstruction is removed ND explain: I Page 3 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 39 Hillard Hay Way,West Barnstable Owner: Richard Trifone Date of Inspection: June 9,2004 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (arid Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance **This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution fi-om 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. 3. Other: I Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 39 Hillards Hay Way,West Barnstable Owner: Richard Trifone Date of Inspection: June 9,2004 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No _X_ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _X_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool _X— Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X Liquid depth in cesspool is less than 6" below invert or available volume is less than %2 day flow _X— Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped X Any portion of the SAS,cesspool or privy is below high ground water elevation. —X_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _X_ Any portion of a cesspool or privy is within a Zone 1 of a public well. _X_ Any portion of a cesspool or privy is within 50 feet of a private water supply well. _X— Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. (This system passes if the well water analysis, performed at a DEP certified laboratory,for 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 forma _No_(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 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 drinking water supply _ the system is within 200 feet of a tributary to a surface drinking water supply — _ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR.VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 39 Hillards Hay Way,West Barnstable Owner: Richard Trifone Date of Inspection: June 9,2004 Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No _X_ _ Pumping information was provided by the owner,occupant, or Board of Health _X_ Were any of the system components pumped out in the previous two weeks? _X_ _ Has the system received normal flows in the previous two week period? _X_ Have large volumes of water been introduced to the system recently or as part of this inspection _X_ _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) _X_ — Was the facility or dwelling inspected for signs of sewage back up ? _X_ _ Was the site inspected for signs of break out'? _X_ _ Were all system components,excluding the SAS, located on site ? _X _ 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 '? _X_ _ 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: Yes no _X_ — Existing information. For example, a plan at the Board of Health. _X_ _ 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(3)(b)] Page 6 of 1 I , OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 39 Hillards Hay Way,West Barnstable Owner: Richard Trifone Date of Inspection: June9,2004 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: i 10 gpd x# of bedrooms): 330 Number of current residents:2 Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required] Laundry system inspected(yes or no): Seasonal use: (yes or no): No Water meter readings, if available(last 2 years usage(gpd)): N/A Well Water Sump pump(yes or no): No Last date of occupancy: Currently Occupied COMMERCIALANDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):_ Industrial 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 occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records: Pumped in Nov. 2003 Source of information: Owners Records Was system pumped as part of the inspection(yes or no): No If yes, volume pumped: gallons-- How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM _XX 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: Compliance date: 10/26/01 Were sewage odors detected when arriving att the site(yes or no): No f Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 39 Hillards Hay Way,West Barnstable Owner: Richard Trifone Date of Inspection: June 9,2004 BUILDING SEWER: X (locate on site plan) Depth below grade: V Materials of construction:_cast iron _X-40 PVC_other(explain): Distance from private water supply well or suction line: 35' Comments(on condition of joints, venting,evidence of leakage,etc.): SEPTIC TANK: X (locate on site plan) Depth below grade: 16" Material of construction:—X`conerete__metal_fiberglass_polyethylene __other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):—(attach a copy of certificate) Dimensions: 8.5' long x 5.2'wide—1000 gal. Sludge depth: 1" Distance from top of sludge to bottom of outlet tee or baffle: 29" Scum thickness: 1" Distance from top of scum to top of outlet tee or baffle: 6' Distance from bottom of scum to bottom of outlet tee or baffle: 13" How were dimensions determined: STICK WITH HINGE FLAP. Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc.): Tees intact and clear,tank not in need of Dumping. Recommend pumping every three years GREASE TRAP: No (locate on site plan) Depth below grade:_ 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: Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Page 8 of 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 39 Hillards Hay Way,West Barnstable Owner: Richard Trifone Date of Inspection: June 9,2004 TIGHT or HOLDING TANK: No (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/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition ofAlarm and float switches,etc.): DISTRIBUTION BOX- X (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.): Box set level, no solids or high stains. PUMP CHAMBER: No (locate 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.): n Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 39 Hillards Hay Way,West Barnstable Owner: Richard Trifone Date of Inspection: June 9,2004 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: _X_leaching chambers,number:Three 500 gal drywells. _leaching galleries,number: leaching trenches,number, length: leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil,condition of vegetation, etc.): No standing water in chambers,sand in bottom is clean and dry. CESSPOOLS: No (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 or no): Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.)`. PRIVY: No (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.): n Page 10 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 39 Hillards Hay Way,West Barnstable Owner: Richard Trifone Date of Inspection: June 9,2004 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. Hillards Hay Way � 32 4 ac� c.� Sq 1.000 gal tank D-box 3 -500 gal dry-wells Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 39 Hillards Hay Way,West Barnstable Owner: Richard Trifone Date of Inspection: June 9,2004 SITE EXAM Slope None Surface water None Check cellar Dry Shallow wells None Estimated depth to ground water: More than 10 feet Please indicate(check)all methods used to determine the high ground water elevation: _X_Obtained from system design plans on record- If checked,date of design plan reviewed: 9/2/01 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: Perc test performed on 8/28/01 found mottling at el.9.15. Plan shows Bottom of SAS at el. 14.36. 'TOWN OF BARNSTABLE LCATION- - 9 I Ct SEWAGE #O W VII:LAGE �� /��e�.� Nc LAC ' ASSESSOR'S MA� & LOT- 3 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY J LEACHING FACE= (type)-3- 066wb 2 y� (size)32 X 3�X Z NO.OF BEDROOMS ny / BUILDER OR OWNER (ov a �� l�awe D 0 PERMITDATE: �— Z b ®/ COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist , on site or within 200 feet of leaching facility) } `C5-0 Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) ` `:,="" 1.5 Feet Furnished by .. �r / '\ ;; ��, . ��` �.o r� _____ :�" �ti p +�,e v O i No e Fee 2�50_1 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01pphratfon for Mf 6pont *pgtem Comaructfon Vermtt A Application for a Permit to Construct( )Repair Upgrade( )Abandon( ) ❑Complete System -k Individual Components Location Address or Lot No. , / Owner's Name,Address and Tel.Ng. st? # /lt wid S e e 4l'j Assessor's Map/Parcel ,36 �� , �j ��j jc%f/ w� Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. �ai3'Gre I� ��� � .fe.. ilc e �irre /-)g<- �'�/r1. e �Fr.�se�•�s ,,.�� 6.4 y oe,*S'7' sANv Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 7 ! gallons per day. Calculated daily flow `l' gallons. Plan Date 17, 2 —a l Number of sheets l Revision Date /1/O N-2 Title Size of Septic Tank W(5T/N4 /000 Type of S.A.S. 330 (� '•¢iyl9e-3 Description of Soil See , ' Nature of Repairs or Alterations(Answer when applicable) Zee Ae_e`46.4.ve6N 6_lz/e ql /4?C-= Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this B Health.IR 9k-.2a' / Signed zycnm Date Application Approved by - Date, H �' Application Disapproved for the following reasons Permit Date Issued t No. �401fl'"!� Fee < r THE COMMONWEALTH OF MASSACHUSETTrS- Entered in computer: PUBLIC HEALTH DIVISION -TOWN Of BARNSTABLEs MASSACHUSETTS 01pplication for 0i!6po$a1 *p5tem Con$truction Permit Application for a Permit to Construct( )Repair(�O Upgrade( )Abandon( ) ❑Complete System Individual Components Location Addregs or Lot No. //� � Owner's Name,Address and Tel.N . Assessor's Map/Parcel 1,36 Installer's Name,Address,and Tel.No. T� Designer's Name,Address and Tel.No. f SL.e Id S4nr�Y Jt�vc 2 �ivc Dec eev4"". /v vAN,lPhAS ,,A., wqy eas7 JAArD �0'"2 rG--rf.,941,e 0"VY F 3 3 P 12 Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) . Other Fixtures ''LL Design Flow T � U gallons per day. Calculated daily flow gallons. gallons. Plan Date 17- 2 - a / Number of sheets / Revision Date Title Size of Septic Tank et�S 1'iivr.,T /000 _—Ty pe of S.A.S. Description of Soil See ,/4 4 Nature of Repairs or Alterations(Answer when applicable) /re,D1A�.4L.4,vc61V �QA Gd! 921 7 Date last inspected: Agreement: _ - The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued y this B alth. Signed Date Application Approved by T - Date' 3 Application Disapproved for the following reasons o Permit Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (Certificate of (tompliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired (,)( )Upgraded( ) Abandoned( )by &SFl P/d S4,17 i 4-A.'eW SPi ti/C (? -r'N C- at 11?9 #111 /A/&S r__4l•9W,4,4 f has been constructed in accordance with the pro Zo(--,5F1-e ns of Title 5 and the for Disposal System Construction Perms /t'' O'O �r dated Installer /c Designer � NV The issuanc of this permit shall not be construed as a guarantee that the syfT wil function as designed. Date ��I P vv1 Inspector 1%C �V. 1.1t, --------------------------------------- Ne. E� Fee `Q THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLEs MASSACHUSETTS lwioogal *pgtem Construction Permit Permission is hereby anted to Construct( )Repair Or")Upgrade( )Abandon( ) System located at v?9 A r//,,4 ,c/S & 4wR S'-7 1;4,, V 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 it. f Date: lam' Approved ! 'i 1 TOWN OF BARNSTABLE LOCATION AZICA SEWAGE # Zoo —G T Z. VILLAGE �� �N�� A/ #- W'6*ASSESSOR'S ' & LOT INSTALLER'S NAME&PHONE NO. .SaN��fcz 20/0 SEPTIC TANK CAPACITY j � c LEACHING FAciLrrY: (type)33`,!`Ee.��l 'G�c�2Vs (size) Z NO.OF BEDROOMS y BUILDER OR OWNER �aa ��c' �Cp"4 e t,-/o-,, PERMITDATE: ?— 2 b o/ COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility ° Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) � � Feet Edge of Wetland and Leaching Facility(If any wetlands exist .•fig:.;<:: within 300 feet of leaching facility) Furnished by t e - V v` V Fmc CK9 4�__ _�HE COMMONWEALTH OF MASSACHUSETTS ;BOARD OF HEALTH ` *5' R .......OF.............................................................................•..........-- f ,��r rlirttfilaYt for Uiipnial Workii Towitrur#inn ramit .. Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewa a Disposal f System at: Lo 41 do -Address for Lot No ....................::....... Owner Add ess !1-+?4w..... M 1......................................... ... !: ..................................... Installer Address QType of Building Size Lot.... _L, .a._0....Sq. feet Dwelling—No. of Bedrooms.........Z..........................Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building No. of persons............................ Showers — Cafeteria d ----a Other fixtures .................................................. - •....•.......---------------------- W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity.LWAgallons Length................ Width................ Diameter..--.--......... Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area...2. tteS.sq. ft. Seep-age Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.....................................................--•.................. Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water..---.----...........--. G4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.....................:-- ----•-•---------------------------••----••--•-•---••--.................................---•-•----......---••-•------•------••--•-••••-•--•........---•-.•--- 0 Description of Soil................................................................-.......------.......------------------------------------------------....._...........--••••......•----- X V ---••-•-----------------•--•--•...-•--•-•-••---•----•----•-•••-•---......................---••------.............•------•--•--------•-•-•--...--•-•-----•----•--.....----------.._..-------••-••-------- W ---------------------------------------•---...-•••------------•-------•••--•--•-•---------------•-------•-•.....------•---------•------•----•---------------------....•-----•----•------•-----........_. VNature of Repairs or Alterations—Answer when applicable.................:............................................................................. --- --------------------------------------------•--•----•-------.............--••--................-------••--••---•-•-------...------...........--••--•-•---•-----------.....----------•-........••---- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been is ed by e boa d of health. --- D Application Approved By.. . ...... .................................................................. ................ Date Application Disapprove r th f ollowing reasons:---•---------------------------------------------------------------------....................................... -•------•-----•--•...............•---......._•--...--•------•---••-•-....•--•----•-•-•.............•••--------•--•-••--•-.....--•••---------..........••-••--•••--------•--•-------------•-•---•...... Date PermitNo................................•---------•-•--------•... Issued........................................................ Date -� ----------------------------------- ------ ----- 44., t z �rHE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..................... ............... ....OF...................................:..................................................... ApVfira ion for Ui,ipnsal Workii Toavuurtion Vamit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: �. . q�>..= 1 r ........... .................................•--•----•-- ---• ---•••----------------...---.................. Location•Address f r ^, or Lot No. Owner Address ............................................ ...... .-- ...... ..................................... Installer Address Q Type of Building Size Lot........ .:_.._.:.. _Sq. feet U Dwelling—No. of Bedrooms.......... ..........................Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building No. of persons............................ Showers G.I YP g ----------•----------------- P ( ) — Cafeteria ( ) al Other fixtures ................................. . W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity-1°__� gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area...:�45#!2`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........................................ Test Pit No. 1................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........................ ----•---------•••-----------------••-•--•------------•...................................................---------•--.....-•---..............-•••-•......--- ODescription of Soil........................................................................................................................................................................ x U ---•--•-------- --••----•---------•-----•-------------------------------••-•-•-----------------.........------------......--------------------...--•-••---------.._........--•••-------.---•- --------------------------•--------....-------•---•----------------------------------------••------------......-----------------•----•---------------•-•---•---------------....._...................... UNature of Repairs or Alterations—Answer when applicable............................................................................................... ----------------------------•-----------------------•------•-•••-----•----•------•----...---.......--•----------•--••--------...-------------------•--_....--••••----------------------......_....-•---- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been is ed by the boa d of health. Si med--- ''_ °'_........................` ��. ._ ..... G ----------------------•----- D e Application A roved By'...-- PP PP '=''.. ........--•--••-•----------------------------•-----•------•------. ------`� �,.__. _��.. Date Application Disapprove or hollowing reasons:..........................................................................................: ................. ------------•----------•-----------------•---•--•-•-------------------------•--•---.................•--••I-------------------------------------•-•-•------------....----------------------------......... Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF..................................................................................... Trrtif iratr of Toutpfiattrit by TH� IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) i .i i staller J._ J/_ has been installed in accordance with the provisions TITLE 5 of The State Sanitary Codve/� ribed in the application for Disposal Works Construction Permit lti'o.__, .y':K. ..._...... dated_../l;<Z_.__.... .......................... THE ISSUANCE _ F THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WIL FU TION SATISFACTORY. DATE 1 .:-f..... 1......... Inspector..... .. .......................... ...... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH T ...........................................OF.......................... No., .....-Ia...... FEE........p.......... �i��ro,� f- ork�. �on��rttrtion rrnti� Permission is h y g anted-- '=•.. . = gg ----••--•-•-----•..................................................... to Construct ( e` air( ) � i 1 'Sew e'D l System ✓ P c' ,. 'r' �f � at No. rr { `cf_:. '. ' ` i J Str.._."1 ..__.. as shown on the ap icati o for Disposal Works Constructio Permit .._ ...........` _ ated........................................ ..._... a:... .:..... .......................................................................... „ 'Board of Health DATE----. 1. Q.. ......... .......•---•-------•--•---•---------------- FORM 1255 A. M. SULKIN, INC., BOSTON