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0018 HOLLYHOCK DRIVE - Health
`118 `Hollyhock-Drive West Barnstable �--- __ A�'195 —028 - 003 C o � SE NDER I C I OMPLETE THIS SECTION COMPLETE rMs SECTION ON D I ELIVERY- ■ Complete items 1,2,and 3.Also complete A.4ignat item 4 if Restricted Delivery is desired. X ❑Agent ■,Print your name and address on the reverse ❑Addressee so that we can return the card to you. B. Received by(Printed Name) C ter D liacery � ■ Attach this card to the back of the mailpiece, i or on the front if space permits. D. Is delivery address different from item 1? ❑Yes 1. Article Addressed to: If YES,enter delivery address below: ❑ No FMS Jane:Show 18 Hollyhock Drive 4 WestBarnstble, MA 02668 i 3. Service Type ❑Certified Mall ❑.Express Mail ❑Registered ❑Return Receipt for Merchandise �— -�-- ❑Insured Mail ❑C.O.D. 4. Restricted Delivery?(Extra Fee) ❑Yes 2. Article Number 7011 0470 0001 4525 6867�► (transfer from service labeo IPS Form 3811,February 2004.is ; Domestic Return Receipt 102595-02-M-1540 I UNITED.STATES,, ' A+�(; j, °�'�„• ,,..r • Sender; Please print your name, address, and ZIP* this box • I � I Town of Barnstable Public Health Division I I ' 200 Main Streety Hyannis, MA 02601 tl rl Postage $ r I Certified Fee NI s p Return Recelpt Fee �� Poshnark O�� p (Endorsement Required) �` Here O p Restricted Delvery Fee 31 (Endorsement Required) p Total Postage&Fees $ : S rl r-R Ms Jane Show 18 Hollyhock Drive West Barnstble, MA 02668 Certified Mail Provides: o A mailing receipt 1 a A unique identifier for yourimailpie&'U ® A record of delivery kept by-the Postal Service for two years Important Reminders: m Certified Mail may ONLY be combined with First-Class Mail®or Priority Mail®. o Certified Mail is not available for any class of international mail. I o NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For valuables,please consider Insured.or Registered Mail. o For an additional fee,a Return Receipt may be requested to provide proof of delivery.To obtain Return Receipt service,please complete and attach a Return; Receipt(PS Form 38111 to the article and add applicable postage to cover the fee.Endorse mailpiece Return Receipt Requested'.To receive a fee waiver for a duplicate return receipt,a USPS®postmark on your Certified Mail receipt is required. a For an additional fee, delivery may be restricted to the addressee or addressee's authorized agent.Advise the clerk or mark the mailpiece with the endorsement°Restricted Delivery°. m If a postmark on the Certified Mail receipt is desired,please present the arti- cle at the post office for postmarking. If a postmark on the Certified Mail receipt is not needed,detach and affix label with postage and mail. IMPORTANT,Save this receipt and present it when making an inquiry. PS Form 3800,August 2006(Reverse)PSN 7530-02-000.9047 I ' r / Town of Barnstable Barnstable BOARD OF HEALTH AlAm eficaMy P � r: )-� 9,�s:„SSSLe,� 200 Main Street, Hyannis MA 02601 �prED MAt A. 2007 Office: 508-862-4644 Wayne Miller,M.D. FAX: 508-790-6304 Paul Canniff,D.M. Junichi Sawauanagi CERTIFIED MAIL# 7011 0470 0001 4525 6867 May 31, 2012 Ms. Jane Snow 18 Hollyhock Drive West Barnstable, MA 02668 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 18 Hollyhock Drive, West Barnstable, MA was last inspected on 5/21/2012, by James D. Sears, a certified septic inspector for the state of Massachusetts. The inspection of the septic system showed that the system "Conditionally Passes" under the guidelines of the 1995 TITLE 5(3 10 CMR 15.00) DUE TO THE FOLLOWING: • The D-box needs to be replaced. You are ordered to repair or replace the septic system within two (2)years from the date you receive this notification. Failure to repair/replace the septic system with the deadline period will result in future enforcement action PER ORDER OF TH OARD OF HEALTH Thomas McKean, R.S. CHO Agent of the Board of Health Q:\SEPTIC\Letters Septic Inspection Failures or Future Eval\Regulatory Authority.doc � � � � �� �', ��p� ,�- I x COMMOnweafth of Massachumft T1 le 5 Officloal Inspection Foy Subur Sw*,qp Sys Form=lei t"very Assessments 18 Ho,-ffio&Dr- Property Snow for every W.Barnstabte MA 026M QWToWrr Of M IJ ins on mutts must be submiftd on tht form.Mspmtton fomw mpy not be awd to any way.t?tease see conrpteteness the cktist at the end of the form VA W; X Genera! Information W,,.o ""OF,�q UM JAMES %,As c -Clow �D.S _�: SEARS so the return Name of Inspedar %�: ••�' 153 Commercial St fill 111111% CarrWimyAddmss. MA 02649 5 77-W7 Sft Te"hene Nwft r Murb-er E. Certification I t fy that I t peirsonafty ff ispx1ed the zmrap dftosgd m at to adftw and tot t information reported hetow is t u%acctmrate.and complete as of time time of time ikon.The irmspection was perfiormed Wmed on my Era g arid in propw hn*m and mairitawce of on site sewapdisposWsysteim lama# tDSectim 9530of 'i Me 5(310 CMR ISAW.The fir: Q Passes 0 CwWftna Passes Q Fads 0 Web FLO#W Evakia—bort by the Local AW*ft Aamthodty 5-29-12 The system Inspector shall emit a copy of this Inspection report to the Apprmrig Auth y(Bowd of Heal or DEP)wWn 30 days of co mpletlrmg this Inspection. tf the system is a sham system or has a design l�l�40ri or�,.t{;the�, �4tor and the� system m shall submit mport t�-`ti-"'MP""f Pm regional Ei4 NiC EiG�.The Q ial shoal br�.1 a; the system owner and copies sent to the buyer,d ate,and the * hn repots o*deacnibn cones at the time of MapeWon apt d undef#w owdUbms at at flint dme.This hmpeefim does not aWress>i of #w s stein}�t'�E#—in&e fEAm,tltt @t the sam or ififtmmt condi one of use. 12-41.1 t&M- Commonwealth of M�assnC � Title 5 Official Inspection Foy 8" Wt for Vduft"Asswwmds Pretty AcKirr�s Jane Sn(M ctstta is W.Bams#able MA 0M pop- c4from state 2* o Of B. Cerffiwfion (cont) Inspection Summary;CheckkBCD or E l Sys complete all of Section D A) system Passem 0 !tave M found avq Mwmahon wtfth huboatm OW any of the fie in 310 CMR 15.E or in 310 CMR.15 304 exist Any failure cri`taria not evaluated are kKficated tekw. Comments; SysWnCendW=WPsssw- One jot Mm systern cwVwents as dwofted in TmMonal PaW sign VIDW to be mph-wed or repaked.The systerrr,upon txxripletion of the reptacement.or repair,as awoved by %,--Board o€Heaffir.,wMpw& Check the box for° ","ram"or gnot t erTmhmW(Y,N,ND)for tt following statements. if tinot i't fined,'please eWaii. The septic tank is metal and ow 20 years okr or the sepbe tank(whettw metal or riot)is sVuo#uraN unsound,a ft subs#antiai Wiltration or eAfftr�n or tank AvUe is ii�iri kient Stein win pass r#if the.eyisft tank is reptaced vAh a can *ft sepW W*as appw£td by the Board€f eab. A sibl septic tank will pass inspection if it is structurally sound, not hmoang and if a of Compliance indicting tat tPte tank is less ton 20 yeas old Is e. D Y 0 N ND(Explain below): i f Commomveaitt of MWmachuseft Title 5 Official Inspection Form Subsur Sy.Um Fm for Vblur 18 Hdyhm* Prot eft Aftfts .#ane Snow nhrnrta is�n W.BsrnsWble MA MM 5-21-12 c ffowft swa zoo-C&ta now Of S. Cerffiwdon (cont.) S) System Conditionally P (cont): Q Observabon of sewage badW or break or high sta&water level in the dstrbufion box due to broken or obstructed pipe(s)or due to a broker sett or uneven dmtribution box System will Pass inspection it{ate approval of Board of Heeler}: 0 broken pipes)are replace[ ® Y 0 N 0 ND(E lain below): 0 ObSOUCODn is feffvied 0 Y . dWibt#Jon box is Wit or replaced 0 Y ON 0 ND Need to repbw D Box Vftft G The system rewired pumping more than 4 times a year due to broken or obstruct pipes)-The s-fMarn wM paw IrWwfion if C*@ aWroval of the Bow-d of Reaft* 0 broken its?are replaced 0 Y ON ONO t 0 obstruction is remove 0 Y ON ONO( bad: C) Fwffw Evaluation is RequWad by this Board of Health: Me system is rt toprotedpublic health, safetyit USG eiFiYfioiii ent I. System wig paw unless Board of Health deter in accordance with 3"CM ISAMN"t )that the systa is not funding in a inanim win Protect Ptdh-ft heaw safety and the sn�rironmsttt: 0 Cesspool or privy iswin50 fW ofaswtwew Cesspool or prWy is whin 50 feel of a bordeft vegetated wed or a san CoTtm#ainwa ltt of Massachuseft Title 5 Official Inspection For System Form- 18 Hollyhock Dn .lane Snow W.Barnstable MA OMG S-21-12 OVTOM sum Zip Cade DOW Of Vapecom B. Cerdficadon (cont) Z System Will fad unless the Boar!of Head(and Pubes Water Supplier,if any) date nh that the ern Is functioning in a mmmer that the pub health, safety andI 0 The System hMS a sew tank and sod abSOrpt10n SyStUn(SAS)mid the SAS is within 100 feet of a surface water supply or tributary to a sw facEe water supply, 0 The system has a septic tank and SAS and the SAS 18 within a Zone-Iofa publicwater wwly- 0 The system has a septic tank and SAS and the SAS is within 50 feet of a prate water supplyweff. 0 The system has a septic tank and SAS and the SAS is less than 100.feet but 50 feet or more from a private wafer supply w �. Method used to deteffte _ This system passes d the well water analysis,perforamd at a DEP certifted laboratory,for fecal coftform bacteria indicates absent and the presence of ammonia nitgen and nitrate nitrogen is equal toorless Ow 5pprn,provided t no cow 1Wture criteria are triggered.A copyof be attached to this form. 0) System Fa*"Cniena Viable to AN You must truftate"Year or'�w to each of t for an ftMPQCftM Yes NO 0 0 Backup of sewage mb hw*or system compo€e€t due to, or SAS or cesspool 0 M Discharge or ponding of event to ft surly of the,ground or surf3m watm due to an overloaded or ckQged SAS or cesspool Sty kiuld level in the dsrlbrZfion box above out pert due to an overloaded or clogged SAS or cesspool 0 0 Liquid depth in cesspool is less dw IF below mvert or available vokmw is less than I day how tsins•1iflo TAe5OWOW mFem%budwe D40W -Pop 4off7 CAmurionwealth of Massachumft Title 5 Official Inspection Form Subsurface Sewage Dhwosal System Form- Not for Wuntary Assessmerft 18Hollyhock PKV8ft Address Jane Snow MWAred for 0" - is W Barnstable MA 0260 5-21-12 POW- c4yrrom stata zip code oft0finspection B. Cerfficadon (cont) Yes No � �fl 4 Wnes in the W yew A10Tdw to clogged or Wm pumped- 0 E Any portion of the SAS,cesspool or privy ts below high ground water elevation. © M Any portion of cesspool or p€ivy is wMa 100 feet of at surftm water$UP*or tributary W a surface wateT supply, Any sofa cesspool orpriWiswift€a t o pubftwdi 0 IR Any portion of a cesspool or pry Is within 50 fed of a private wad sum well:. 0 0 Any porWa of a psi or privy is ins than i00 .but Weald than 50 feet from a pry waW supply well with no aoceptabie wester ditty anatye rnft system passim 9the well water anahists,panted at a DEP certified labo fecal rAwy, bacteft bdkMes absent and the pi esence of ammonia nitrogen and nitrate non is equal to or Ins Vian 6 ppm, provided OW no other fallure criteria are mod.A copy of die analysis and chain of *must be attacind to this ficm 0 0 �,�is a cesspool serving a� a design of 24� 0 0 Tlo sysftm fat' .t have deter that one or more of the above fagure criteria exist as dsscbad in 310 CMR 15.303,therefore the system fad..The system owner should contact the Board of Health to determine what will be E) Lame Systems; To be considered a hop system the"stem must serm a facility wills a desi i fkRV Of 10,E MW to 15,000 gpd. For Wge systems.youu must indicate either=yeses or ate*to each of the followkxj.in addition to the questions in Section D. Yes NO Q ' 0 the system is wilt 4W€eet d a surer drinlc g water supply 0 0 the system is wry 200 feet of a bflxdwy te a surboe dri*kQ per supply 0 0 the system is located in a n&agen sensitive area(Intem Wellhead Protection Area—IWP#)or a mapped Zone If of a pubic water supply well If you have answered W to any question in Section E the system is considered a sill'i threat or answered Oyee in Section C above the large system has fed,The owner or operator of any large system considered a soAcant direst Sit E orb undw Semen 0 be system in accorrlance with 310 CMR 15.304.The system ownier st=W contact ft alWvpriate regional office of the Department. ins•if110 T&-6 offbat ftpecbmFasm:st�sewagen e►item-Pagesora7 i of E its Title 5 Official Inspection Foy . �i _ or Voluntary Assearnerft 111 Ho%O Dr. Isnow W.Barnstable s 5-21-12 CWTaWn suft ZIPCOft DMOf C. Chet Check N the folios have been cam_You must fnd=ft W or OW as tD each of We kftmW Yes to Purnping InIbmuffion was provided by the owner,o=MaK or Board of Health 0 0 Were my of the system con"nerft lump out in the pests 1 0 0 Has the system recerved normal ftms in the pevious two week perwd? 0 CK Have large vokmve of water bew introWeed to IM systern Draspartal this ins ? 0 Were as tit plans of the system of to d and warnm (N#W were not as MA) 0 0 Was the facility or dwelling inspected for wanss of sewage back up? 0 Was t two 0 0 Were all system cmrQonents,exdtdM the SA.%bcated on site? 0 0 Ware the MWtank manham urmvered,opened.and the soft UM irk tar the c ondi on of the bafts or tam trudenal of c onstruchon, dimenvons.depth of liquid.depth of studge and depth of scum? Was the facility owner(and oocupants N diffennt from owner)provided with on the pmper maintenance of wbsurl vpWW. been defined ism on: N 0 Bating in€anabm For example,a plan at Ord of Heaft 0 CK DeMaraned in the f (if any of ft faRve cr re to Pat C is at mm apprwdrnafion of distance is u )t310 CMR f 5_ (5)j F D. System Information Reskhw"Flow CoWfffons., NA Number cif brooms(design): Number of ems(actual): �: DEMN flow t on 310 CMR 15.203(far emyq*: 110 go x#of bedrooms).- MO Title 5 Official sperm n Form Subsurftce Sewame Dkwasal Sy.4m ftm-W tr 18Hd1ytto&DL ftAftm .lane Snow ors is W.samstable MA 82M 5-2`c-12 MWAMdfWOMY• CWr0vM state Zip code 0M Of woe D. System In motion Number of current residents. 0 Does residence have a garbage grkxW? 0 'des N No is m an e separate SWAMW sue?Pf yes separate Mspectim mWndl 0 Yes 0 NG !.awry system lirpected? 0 Yes M No seasonal use? 0 ye 0 f Water meter rea p W avaffable(lad 2 years usage( ): SUMP PUMPI? 0 Yes JR No Last date of occupancy. unknown Date Type Ofend, Basis of din ftow(qeaWPWWfW ft, ). print? 0 Yes 0 No kswW-aste W&V tW*WSW&? 0 Yes 0 to Non-sanitary waste discharged to the Tide 5 syshnyO 0 Yes 0 NO WMarmetermadhp:famdabW_ -��na sceran &bantamsr,- rer I Commonwealth of Mas Title 5 Official Inspection For Assesmients 18 Hollyhock D �AddMs Jane Snow WOMMOM is of W.Barnstable MA am 5-21-42 PW. Wrom sty zfp GO& Date Ofkmpeaboft D. System Information (cat.) Last date Of o=*astoy use. DBL- Odw(dam belowy �g Source of ittfonnaa#on. Was system pumped as part of the hrispectim? n Yes M No tf yes,uokMW purnpe& g Hoer was quantity pumped deed? Beason for pump : Ty"ifS sod absorptf system Q 0 overflow cesspool 0 Privy 0 Bhp system(yes or€o)(If yes,aft ptribus{nspecbm reoords,If arty) 0 lnn&raMWAl1ernaWe tedwology.Attach a copy of the cures openabort and rttainenance,axUract(to be obtained fret sett owner)and a copy of lam irtspection of the I/A system by system operator under=Araa 'i%M tank- Aftch a any of the DEP approval. •ii°t4 Tii�� it Ftxta:�S Qisp�t •Pe�B�iT i Commonwealth of Massachusetts Title 5 Official Inspection Form since$wow ftpwW sr$=Form-"for Voluft"Awewrtenls 18 Houck Dr, JmeSmw W.amble MA 0M 5-21-12 page. CRY'rram Sint& zio caft Of ftmpocow D. Sim Information (,con j APPr0xMU*ap of all empoftift date MsWW(d kwm)and source of Mwma m 1985 Were sewage odors detected when arrWinga the site? 0 Yes 0 He Bidtift Sower( on site Rom)= Depth be gr = i, fad Ulate"of constrtu n: 0 40 PVC 0o#w€ems) DWA=&from private waW supply well or suction ice; Commesfs(on coed n of puft-0 vim,.evxWm of Jam,ex y fttft is 4:pvc sc Sephe Tank(kcate on sft plan): �f 0 0 mew 0 fbwgWs Opolyethylene 0 ot1w( Wn) YOM tit Is age corffirrred by a Came of Comte?(allach a cM of cerfficate) 0 Yes 0 `ft Dim€ms : 1 Sludge depth: T .lino TftS0MCWkMPKWnFbM - �. Conmion lth of Title 5 Official Inspection Form fcw NkkmtwY Assesunents 18 H044 c DL PwpeftAftm o Snow 040MOka isW.BarWab(e MA 02888 8-21-12 OfftmPeCOM D. System Infonnation (coat.) Sopfic To*( ) DWance from top of skids to bottom of outlet tee or ba Scum tWK*ness g Dista�from top of aim to top of outlet tee or baft 12" # n bottom ofscum to bottom of outIPA tee or baffle i t How were dimensions ? TW pad regod sudge judge C�k - (on e C,C Fr m a r daft r s,h*t apt oil tee or liquid WMs as related to oil Invert,evidence of leakage,e.). Tank and covers at$'below grade, En€et tee out baffle No sign of fe~or aier loading Owns TiRP(tocate on Deo beIMN Waft- Matte of Ot t: f-1 cor"eL- metal 0 offw try 1�i33�1S342i1S; ii'4'3 Otickness DWWZ---Rom top ofSOMto top ofot"tee- ofbaft Obance from bottom of scum to bottom of oil tee or baffle Daleof Jast pmW1nW tfs-i1Tto Tift S OMCW ti en Farm:S Sewage D40W Systam•Pap 10 arlT Connnonwealth of AN i ias h� Title 5 Official spectio For f8 Eck D t'ropeft AddrM .pane snow ftftMwftn is W.Barnstable MA 02 5-21-12 Wrom sta* Mp Cade Do*of ftwMCOM D. Sim Information (cont) Cwments(on punk Wet and outtet tee or bale=tion,struettual mom, tiguid tens as Mated to outtet invert,evidence of Ceakagek etc.): Hof MOM Taft(Uft must be atbmeof' )(em on s Depth belm Wade- Materlat of ooucticn: [I=wrete, F1 metal 0 Wm 0 othu(ee)- t�s Capaw- ten Alann prat: 0 Yes ONO Abrm tevet AbrmkwmtWgvrdar 0 Yes 0 No Date of tit pumping: Commen#a(co Wtm of alarm and )= COPY oforntpumpkv .Is copy ar 0 Yes 0 t t9ft-MG T Me 5 0rdCW&qMCffM Fam-Subufffbim Se ap Dim S -Pep l t of 17 COntmwri maM of Maaaachuseft Title 5 Official Inspection Foy f€ -tfwWme"Awmmwft PmtxftAd&wm Jane Srom ;ftumam isW.BwrmMbie MA S-24-12 D. Sim ift Orl(e ms.) Dtetribuon tax(if Ott ffmg t*opwmd)f #eon site fit): Dep1h of fiqud WM abow o t Don ee(rw*if box is W%W ad&ft*t to&Aeft ems,any evidam of wkft cwrymff,,any wife m of Lease into or out of box,etc.): D Box Is 16"x 21" 1T Betow grade w 12 tine's out watts gorve nee to sere Bm PMW ( PwfPS in Vffidft one: F1 Yes 0 No .on 0 Ye 0 No Comment(note coadifion of tmp dmnber,oomfifim of putrq aid etty SOMsaMdan SyMm(SAS)(DcateoapUbke) requW N SAS te)#Wn whr. ems-i Tt1G Title 5 FOM Sub i dbCa D -Pap U Of IT Commonwealth of Massachusetts Tie 5 Official Insertion Form SP*M€ - 18 boa Du .fane Snow o 000maon is W.Barnstable MA am 5-21-12 MvAmdforewy Pap. cKyrrOV& State zio code Dam Of tit D. system ( ) Type; 2 0 Wa&&V dMmbers 0 Ong gagedw number 0 lea�fry num!".Wvft 0 feat nub, ansions; oierf1m cesspool m e system Typalnme of no Coifs(ram condwon of SCOL Hof 4&SUF of s 0ondifim- vegetation,etr--Y- Pits are Ir below grcide,pft are wet stain Ws at 10&Ur No sign of io%w, tadkv or solid cany over 4'stone Cesspools(cesspool must be pumped as pit of )(locate on site plan), and cwfiprafim Depth—fop of"to Inlet art Depth of Sords tftw Depthof scum fay Dimension of Mats of construction fnAcafion of groundwater Wftw 0 leas ONO tym- T1ftS0ffWdM4pAcft �Subsutfam D -Ps pIWIT Commonwealth of Nhm=chuwft Title 5 Official Inspection Form ,8H^fta DL PfopftAddrm .fare Sft= owrulws UP; if♦t.Sam MA Q2 5 5-21-42 page. SM& zio cede Date of topeewn D. System h1fornmullQn (CDnt) Comments(note=xWon of sod,sf s of hydrwk lure,level of M,mxftm of vegebam etc.): ftft(tea on Depth of solift s-ttMO Ti&5 1 eft System-Pap 14af1T i i Titlecoma huseft Inspechaon Form : -amdawa MA om Si -r -ewe Zocaft Syston fnkwma (mil a 3 t } } f r- U4 '. j WI ems•�'€ v � ? ,. :� -- �� y.. i f • - Commonwealth of Massachusetts Title 5 Official Inspection Form - Vokint"Assimiffmits 18 HdW Dr. Snow #ft,"Homis W.Saenstabie MA 02668 5-21-12 Pap- eMAM Stm zio caft am Of 1). system:11'1 1` #on (Cont) SAS Exam: Che&Sk4v Surboe,water Che&ceffw Shy wegs Estirmated dew to high ground w 1 ' Please indicate aH methods used to determine the high ground water elevatim 0 Obtained from sum design pis on r000rdr If cheesed,date of design plan reviewed. o 0 Observed site(aWftg prop VARLAR I hote wiftn 150 fsst of IR Checked wfth IoW lid of Health-aVaWr 0 Checked wfth local excavators,W -(ate rioo�� 0 Aamsed USW You must desafthow Wit, the NO grotind waW - ` G.W Taken off Past Refit T.H. at B.O.H. 12-10-84 NO WaW at i Before filing this Inspection Report,please see Report completeness Checidist on next page. �tirts-tti{0 Tee 5 OWMW ftpecffm Rim.Subawfete SmW WmpwW System-Pew 16 oft7 Commonwealth of L11assachuseft Title 5 Official Inspection Form SW*Urb"S SYSUM ftM-W W\ADkMb"Amunwrmft 18 Y M. Prt�erty Astdt� Jane Snow ntfsK�t�a�s is �. W.Barnstable MA 02 5-21-12 Pap- east stm zip Go& 0M of ftspectlan F- W It cop1-19ness ch€d€ W Inspection S ma ..A,Bp C,DrorEcehecited 0 InspK"-t Smeary 0 Afstem l Am Qeda Afic"to AD Systems completed El System Ir t €n—Estimated depth to high groundwater Q Sketch of SwAsge,Daposat System e leer drams an page 15 or attached insieparate I f -fftf4 Tme5Of ewkMPKfiMgym: %MSavagethsy08afSystem-POP f7a f7 No. '2OIZ- - 130 Feet too D� THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS YeS 3ppl Latlon for mis oBal *pstem (Construction Permit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. /6 Molly C D/- Owner's Name,Address,and Tel.No. Assessor's Map/Parcel W`lZctMV-rAtT 19,566d3 SN0,0 Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. �Sl�s 4ra�wan►c I)rpe 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(min.required) N gpd Design flow provided AM gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. / )14 Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signed Date Application Approved by Date S i2 Application Disapproved by Date for the following reasons Permit No. 2-0 lZ Date Issued — l2 No. Fee"—1 yy .__ THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 0[ppYication for his osaf6pstem Construction Permit Application for a Permit to Construct( ) Repair ) Upgrade( ) Abandon( ) 0 Complete System ❑Individual Components Location Address or Lot No. 18 1-1,911y&rk Of Owner's Name,Address,and Tel.No. w,Zc t,Xs�- ',at-f /�dagV3 SNo1.c7 Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. �SA A Type of Building: Dwelling No.of Bedrooms N Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided Ayf gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. /j Description of Soil Nature of Repairs or Alterations(Answer when applicable) ��x ``eA�G GC'M r i Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signed Date ? f Application Approved by Date Application Disapproved by Date for the following reasons Permit No. i Z �'� Date Issued 15 2�r 7.0(Z- THE COMMONWEALTH OF MASSACHUSETTS _ 1 BARNSTABLE,MASSACHUSETTS s Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( ) Upgraded( ) Abandoned( )bya�& A o,,l G s '�3 to � at : p0&1� 0(LSl4SN G�0'1C has been constructed in accordance 'y" with the provisions of Title 5 and the for Disposal System Construction Permit No.2012— « dated 5 Zs zo IZ- Installer Designer #bedrooms Approved design flow gpd The issuance of this permit shall not be construedas a guarantee that the system will function as designed. Date /c I' Inspector r` •--------------- ------------- ---------_ --------- - ------- ro No. 210 C?_ _ I 9L o r Fee /VT�0,) THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS /Disposal *pstem Construction permit Permission is hereby granted to Construct( ) Repair(IC,) Upgrad fe( ) Abandon( ) System located at �8 1,41 1h()C)( Wes' G WC Ac,h I and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permit. Date qZ I Z-O I Z_ Approved by ' Commonwealth of Massachusetts 0.1 Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 18 Hollyhock Dr. Property Address Chris Snow Owner Owner's Name information is W Barnstable Ma. 02668 4/11/2007 requi�ed fcr 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 fillirg out forms on the computer,use 1. Inspector: only the tab key to move your Robert Paolini cursor-do not Name of Inspector use the return key. Capewide Enterprises,LLC Company Name P.O.Box 763 Company Address Centerville Ma. 02632 ' reorn City/Town State Zip Code (508)428-4028 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the`, information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on,'Site sewage disposal systems. I am a DEP approved system inspector pursuant tp.-Section,_15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ' rn ❑ (Needs Further Evaluatio a Local Approving Authority, 4/13/2007 Inspector's Ignature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. 18 hollyhock dr.-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 15 I I ; Commonwealth of Massachusetts. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 18 Hollyhock Dr. Property Address Chris Snow Owner Owner's Name information is W Barnstable Ma. 02668 4/11/2007 regt.ired for 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: The septic system is in proper working order at the present time. 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: r ❑ 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 18 hollyhock dr.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 15 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments c 18 Hollyhock Dr. Property Address Chris Snow Owner Owner's Name requrea:ion is required Barnstable Ma. 02668 4/11/2007 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 I e s . The Y q P P� 9 Y , P�P O system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ obstruction is removed ND Explain: C) Further Evaluation is Required by the Board of Health: ❑ 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. 18 hollyhock dr.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 18 Hollyhock Dr. Property Address Chris Snow Owner Owner's Name requiraton is W Barnstable Ma. 02668 4/11/2007 required'for 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, performed at a DEP certified laboratory,for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 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. 18 hollyhock dr.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 18 Hollyhock Dr. Property Address Chris Snow Owner Owner's Name information is recluired for W Barnstable Ma. 02668 4/11/2007 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): 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- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ ' the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 18 hollyhock dr.-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 18 Hollyhock Dr. Property Address Chris Snow Owner Owner's Name , information is required for W Barnstable Ma. 02668 4/11/2007 every page. CitylTown 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 El ® 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 breakout? ® ❑ 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)] 18 hollyhock dr.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 ' Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 18 Hollyhock Dr. Property Address Chris Snow Owner Owner's Name information is required for W Barnstable Ma. 02668 4/11/2007 every page. City/Town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 Number of current residents: unknown Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d well water 9 ( Y 9 (gP ))� Sump pump? r ❑ Yes ® No Last date of occupancy: unknown 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): 18 hollyhock dr.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 18 Hollyhock Dr. Property Address Chris Snow Owner Owner's Name information is required for W Barnstable Ma. 02668 4/11/2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool I ❑ 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: 1985 Were sewage odors detected when arriving at the site? ❑ Yes ® No 1f hollyhock dr.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 15 ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 18 Hollyhock Dr. Property Address Chris Snow Owner Owner's Name inquired for is W Barnstable Ma. 02668 4/11/2007 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): 1' I Depth below grade: feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: 20'+ feet Comments (on condition of joints, venting, evidence of leakage, etc.): Joints appear tight.No evidence of Ieakage.System vented through the house vents. Septic Tank (locate on site plan): 1' Depth below grade: 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: 10'6"x5'10"x57" Sludge depth: 411 Distance from top of sludge to bottom of outlet tee or baffle 27" Scum thickness 3" Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 13" How were dimensions determined? Measured 18 hollyhock dr.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 f ' Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 18 Hollyhock Dr. Property Address Chris Snow Owner Owner's Name information is requirec for W Barnstable Ma. 02668 4/11/2007 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.): Pump tank every 2-3 years.lnlet and outlet tees are in place.Tank appears structurally sound.No evidence of leakage. 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): 1f hollyhock dr.-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 i ' Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 18 Hollyhock Dr. Property Address Chris Snow Owner Owner's Name requira:ifo is W Barnstable Ma. 02668 4/11/2007 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 No 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 is Ievel.Box has two outlet laterals with equal distribution.No evidence of solids carryover.No evidence of leakage into or out of box. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No tf;hollyhock dr.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 15 ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 18 Hollyhock Dr. Property Address Chris Snow Owner Owner's Name information is required for W Barnstable Ma. 02668 4/11/2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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 su ply enters the building. UJQ7 ,I \ < 3©i X o - b s 18 hollyhock dr.-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 18 Hollyhock Dr. Property Address Chris Snow Owner Owner's Name information is required for W Barnstable Ma. 02668 4/11/2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells Estimated depth to ground water: 130' feet Please indicate all methods used to determine the high ground water elevation: "❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ® Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database—explain: You must describe how you established the high ground water elevation: Used:Gaherty& Miller Model 12/16/94 ground water elevations.Used:USGS well data June 1992.Used:Technical Bulletion 92-000-01 Plate#2 annual ranges of ground water elevations. 18 hollyhock dr.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 7 ' Commonwealth of Massachusetts iu Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not-for Voluntary Assessments 18 Hollyhock Dr. Property Address Chris Snow Owner Owner's Name information is required for W Barnstable Ma. 02668 4/11/2007 every page. City/Town State Zip Code Date of Inspection i 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): e If SAS not located, explain why: Type: ® leaching pits number: 2 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields ' number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system z Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Sandy soil.No evidence of hydraulic failure.Leaching pits were empty at time of inspection. 18 hollyhock dr.•08/06 i Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 15 I ` Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M. 18 Hollyhock Dr. Property Address Chris Snow . Owner Owner's Name information is required for W Barnstable Ma. 02668 4/11/2007 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.): 18 hollyhock dr.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 O OF B •RNSTABLE A LOCATION ` ;, ;VI-SEWAGE #ZA `0Zg �a VILLAGE ;�•, _ ASSESSORS MAP LOT kNSTALLER'S NAME 6z PHONE No. v� �p'SEPTIC TANK CAPACITY ✓ r E L NO. OF BEDROOMSEACHING FACILITY:(type) (size) l PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER �, 00 DATE PERMIT ISSUED: iGlz 4 DATE . COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No ' �r, .� vl. . .P -+ �d No........-6---_....... ..........._........... _ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH �'6.LAI'-1 .-.OF...... A'!Zn/S?7 .................................... Appliratiun for Diipuaal Workii Tunitrnr#'tun ramit _ Application is hereby made for a Permit to Construct (--) or Repair ( ) an Individual Sewage Disposal gSystem at: ----.._...........................•----------------------......................_.__- --------------------------.......----------r...L--•--- f/� A-uG—� Location Address or Lot No. TLi ti ..................... ...........i.`?. s �-� !�. S:....... - -.....�... n -,. Address -- •............. ---------- ------------�r�....... .._..._.. ......_..... a Insta Address d Type of Building — Size Lot..... ...................Sq. feet . ., Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Aq Other—T e of Building . No. of persons............................ Showers — Cafeteria Q' Other fixtures ..-----••...............•------- . W Design Flow..................5�................gallons per person per day. Total daily flow____.._..�o........................gallons. WSeptic Tank—Liquid capacity_ls ?.gallons Length_!1!6...... Width................... Diameter________________ Depth S_......_-- x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..._-__�_.._...... Diameter......Z`� Depth below inlet....3: ........ Total leaching area._3aZ_9..sq. ft. Z Other Distribution box ( ) Dosing tank ( ) )c,: '`�' Date DK: Percolation Test Results Performed by........:................................ .... _....._....... .... �a Test Pit No. 1_G_. ------minutes per inch Depth of Test Pit..../f5�¢...... Depth to ground water,.... .............. Li. Test Pit No. 2---G.Z....minutes per inch Depth of Test Pit.... ��..._Depth to ground water------�._......_.._ RS -----------------------------------------------------------------------------------•---......-•............-------••-•------._..........__........-----....-- 0 Description of Soil.........a��- 4u 7D�?Soi� _/ �� !'f� _..SA?v� V 3�Vev ------•. .. ..... •.•--- ...................... V .................. .............-................---................................................................................................................................................ . -------------------------------------------•----------------- -------------------------•-----------------------------------------------•----........................................................... U Nature of Repairs or Alterations—Answer when applicable..........5��..--_1, !. .......................................... •-•-•---•-------------------•------••------------•-•-----•-•------------..........-•-•----------...-•---•--••--------------------------------•-•-•-•---------------------------------------•••--•------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System.in accordance with the provisions of iIT 5 the State Sanitary Code— The undersigned further agrees no to place the system in oV 1 rti' of Compliance-ha the boar Signed....... . ----• ....... .. . .•.... ....... ... ... ......� Date AApproved BYY " S f Date Application Disapproved for the f oll ing reasons:................................•---......--•-•---.......-------------------•---•-•------.......•----....._.. ....---•-•----•-•..................•-----•---................................----•---•---....------...............................-•------••••--....------------------•-•---------... ......------. Date PermitNo....................................................... Issued....................................................... Date ------------------------------------------------- x` No........................ Flss............._............._ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH -.<� w/✓...... F......e/�7�ni 5'TfI BGG .......................................................................... AV__p iration for Disposal Works Cfonitrurtion rrmi# Application is hereby made for a Permit to Construct (,-I or Repair ( ) an Individual Sewage Disposal System at: ...............aGG �-�"�=lC•--• 1� Ip/E-sT b'i i vSTf GE� ........................................ La2, Z Location-Address or Lot No. L Glz f.� i ................•................- ......--•---••------•---••-•--......•.•.... . .............................................,/.................................................. Address a -25.4........... -------------- I ........... ..... .. Z...-�'t�!ti...e c-..:'I'�Ts ............... Installer Address Type of Building Size Lot..�..�38.._..Sq. feet Dwelling—No. of Bedrooms...................... Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) dOther fixtures --•---•-----------------•-----------....-----------•--....----------•---------------•--•-------------- W Design Flow....................'-f_—._.............__gallons per person per J y. Total dail flow........... ....•...........--...... 1 . If WSeptic Tank—Liquid capacity.�fb'gallons Length.�`.6.._... Width..s� ..._. Diameter-_ Depth x Disposal Trench—No. .................... Width........'............ Total Length.................... Total leaching area..................... q. f t. Seepage Pit No....... '._.__._... Diameter.__....�`......... Depth below inlet....3.5...... Total leaching area---3c' g_.sq. ft. z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.............................................../. . .. �.. i98¢ W G z �-;7--------------- Date Test Pit No. 1.._G..y....minutes per inch Depth of Test Pit._.__��� ��.. Depth to ground water........................ G>~ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ '13 D Description of Soil.........a-�-Z¢....._70P i�- Z4"_ ML-� 5/•>�i� � 111� / U -•-•---•--•-••--------•-----•••--•-•--••••••-------------------•---•-•-•-••..................-•-•--••-•------•-------•--•---••••---•---•----•--- W U Nature of Repairs or Alterations—Answer when applicable.......... ----------�_ ..................................... ----------------------------•------..........------------------------------------------••-••-.-•--•---•---•.....--------•-•--•--••--••••---•----------•-••-••-•-•-•.•-••--••-•••••-•-•--••--•-••--••-••• Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the.provisions of TIT 5 g£the State Sanitary Code—.The undersigned further agrees not to place the system in operation t l C tifi ,te'of Complia ed by the boar o ea .-c. Signed ..... . ....... ��/" ... -------••---. .........••-- Rat AVc�' on_ApprovedUZo�n B . -- -•--. -•--- ... ...--•-•-•-••-------.---•- PY---�----•- �- -•-•---•----•----...Date--•------- Application Disapproved for the f oll ing reasons:-----•••••••......-•-------------••-----•--------•----••---•--•-•--•--•-..................................... -----•--•-••-•------•--------•-----•--------------------------------------------------------••------...---•-------••-•..._..----...•---•----•--•--•-•-----•---•--••-••••-•----•---•-----•-•---••--•-•--- Date PermitNo..................................................._...:' Issued-....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ......................... ........................................-•----....................... Tatifiratr of Tompliatnrr T fS by J Q CE IFY, That th �I �jSSew Disposal System constructed (✓) or Repaired ( ) .1-- . P $' .................................. -....- - -----•-------•-----•...........................•........---------••-•-••••----••......•-•_.... I taller has been installed in accordance with the provisions of TI t LF 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No......................................... dated.............. _ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE........----�. ._ . j.]..................................... Inspector.........T.Jh•.----_..... _.._1 ` Etillib"k- Ydly V t.v%f, THE COMMONWEALTH OF MASSACHUSETTS +. f T ic"LI _j 0v "(t-t Scat ('raheA,j toe, �l"�E N(, BOARD OF HEALTH vW +� �i,9,ti c pv vbtv�'7 +d+, . Com e t{r"Ay)All, �,�1'rZ�VSTLI 73G C � 1 ..........................................OF.................. . vim. No. tX1►IAl I rl #Atl EE Ito orko �u ion ,rrmit Permission is hereby granted _g.—--•------ ---------. G�.. ---•----------------•-- _- to Construct ( or Repair.( ) an Individual`/,Sewage Disposal System at No.............: -.{ ..._._. /!= G7 ... r Street / as shown on the application for Disposal Works Construction Permit No........... ..... Dated.... : .�' _-.. -- - -.--•-- --•- o d of Health DATE...............I 9 .......................... FORM !�255 A. M. SULKIN. INC.. BOSTON a y �• '57 .C- 7- I OF I ` Po j a S O E p o t KELLE( ' ¢ No. 26100 �� _ �� I ` W 1pf Gl ST ER�� / tv P s d 1 SE�eu go+ ,1 LDCATION wrsy-..6;4r�� >s .eEYi3�D 1 e t 0 Z SCALE . .....�. . . . DATE . PLAN REFERENCE .. ..�. .. . ... I I I CERTIFY THAT THE ...... A/0 C G �10 c!�SHOWN ON THIS PLAN IS LOCATED ON THE OROUND AS SIiOW,N HEREON AND THAT IT CONFORMS TO THE v SETBACK REQUIREMENTS OF THE TOWN OF WHEN CONSTRUCTED. A2 V. DATE . .. . .....: . . .. . REGISTERED LAND SURVEYOR CC2INi - l��T/Tiow"7e' .• ` I L. TOP OF FOUNDATION CONCRETE COVER CONCRETE COVERS 7_ ,' 0 4 CAST IRON II " OR SCHEDULE 402 MAX. 12"MAX. P.V.C. PIPE .. 4"SCHEDULE 40 PV.C.(ONLY) ' ' PITCH 1/4"PER. PIPE- MIN. LEACH PITCH 1/4'PER.FT PIT ?'o PRECAST o' NVERT u LEACHING ° EL•!¢/••�z•• INVERT INVERT ? . Q ; PIT OR o'. SEPTIC TANK � DIST. , >_ ; _ EQUIV. ,•o INVER .T EL. 4/. .o. BOX EL..... GAL. INVERT 3.6 oa EL. INVERT w W 0: :;; 3/4"TO I V2' EL!`x°,ao e• ka U`: WASHED e j 4Z-13b" w STONE PROFI LE OF GROUND WATER TABLE SEWAGE DISPOSAL SYSTEM n NO SCALE SOIL LOG WITNESSED BY : DATE DK. !j!5 TIME. ����'�' fr> CiF�ia ° BOARD OF HEALTH r TEST HOLE I TEST HOLE 2 F2/ w�G �tatd�" � ENGINEER ELEV. . .��v. 775P �pso�� DESIGN DATA ,a-I.A915"o e �l /4z.So NUMBER OF BEDROOMS TOTAL ESTIMATED FLOW . . .��C3 . . GALLONS/DAY BOTTOM LEACHING AREA �53- �. . SQ.FT. /PIT/a,,07�. S -fD SIDE LEACHING AREA . . . I�3; 9. . . SQ.FT./ PIT138-6_G,,RD. GARBAGE DISPOSAL .!�°^!��. .(50% AREA INCREASE) TOTAL LEACHING AREA . . 3c' • .� . SQ.FT 144 ++ PERCOLATION RATE ?��!`!o MIN/INCH Na WATER ENCOUNTERED LEACHING AREA PER PERCOLATION RATE .!�!�. SQ.FTIG,p,D,. Z NUMBER OF LEACHING . PITS . . . . APPROVED . .. . . . . . . . . . . BOARD OF HEALTH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . DATE . . . . . . . . . AGENT OR INSPECTOR OF CF- z +e�•� 4o ED AR q yes •� sT CA __V ELLEY 0.5 00 PETITIONER J��ES ��• .��•��• -� Do�l�? s OFFICE LABORATORY l - 1498 HIGH STREET 176 PLYMOUTH STREET BRIDGEWATER, MA 02324 BRIDGEWATER, MA 02324 OLIVEIRA ENVIRONMENTAL LABORATORIES, INC. FOOD- DAIRY PRODUCTS-WATER-WASTEWATER CHEMICAL& BACTERIOLOGICAL ANALYSES 697-26M May 12, 1986 Pioneer Pump Co., Inc. 21 Spinnaker Drive Plymouth, Mass. 02360 Source: Well. Water - Bored Wello•with well point - 100 feet deep - producing 12 gals./min. (4 inch PVC Well) Located on the property of Mr. John D. Allegrini - Lot 2 - 18 Hollyhock Drive E. Barnstable, Mass. Coliform Count /100 ml @ 35 C Membrane Filter 0 S.P.C./ml L 1 @35C Color (APC units) 0 Sediment none Turbidity (NTU) 0.15 Odor none Taste satisfactory pH 5.7 Specific Conductance micromhos/cm 65. mg /liter Total Alkalinity (CaCO,) 5.0 Free CO, Total Hardness (CACO,) MID Calcium (Ca) 4.80 Magnesium (Mg) ' 98 Sodium (Na) 7.00 Potassium (K) • 50 Total Iron (Fe) Manganese (Mn) 670 Silica (SiC,) ' Sulfate (SC,) Chloride (CI) 13.5 Nitrogen - Ammonia Nitrogen - Nitrite 0.002 Nitrogen - Nitrate 1.75 Copper (Cu) _ L = less than On site collection made by Mr. David Klein of the Pioneer Pump Co. - 5/7/86 at 9:00 A.M. Sample delivered to laboratory by Mr. David Klein - 5/8/86 at 8:00 A.M. Bacteriologically, this well water is of a satisfactory sanitary standard and is suitable for drinking and domestic purposes. Chemically, this well water is acidic and will be corrosive. All other chemicals tested meet the standards. cc: Board of Health Barnstable, Mass. Director a 9 ♦y f • The Standard-Plate Count indicated the general bacterial population of the well at the time of collection. Coliform Group Bacteria: Significance The coliform group bacteria includes organisms found in the intestinal tracts of warm blooded animals, birds,decaying organic matter(hay, leaves, wood, etc.), the top 2 to 3 feet of the soil, lakes, ponds, brooks, rivers, drainage and types of vegetation. Because the organisms can cause some illness; because the presence of coliform organisms in the water suggests that other more harmful organisms may be present, water containing one or more coliform group bacteria per 100 ml of sample should not be used for drinking or cooking purposes unless boiled 5 minutes or disinfected by other means. This bacteria is of animal origin(intestinal tract)and may be considered as closely associated with disease causing organisms.On this factor, none should be present. Color — APC Units- Ground water ought to be practically free from color. For attractive water- color should not exceed 15 units. Turbidity — NT Units- Recommended limit not to exceed 5 units. Odor& Taste — For water to be of high quality, the water should be odor free and taste good. pH — The pH value defines the concentration of free hydrogen ions in solution. Expressed on a scale extending from 0 or very acid to 14 or very alkaline with 7.0 being neutral. Specific Conductance — Conductivity is a good criterion for measuring the degree of mineralization and assessing the affect of diverse ions on chemical equilibria. h alkalinity of this water represents its content of carbonates and bicarbonates. Total Alkalinity The a y p Free Carbon Dioxide — Well water having a low pH and a Free CO, level in excess of 50. mg/I will be corrosive to iron, bronze, brass and copper tubing and fittings. Total Hardness Standard not to exceed 50. mg/I. Waters having a hardness level of 50 to 100 are in the medium hardness range, over 100 very hard. Calcium -- Calcium contributes to the total hardness of water.Appreciable amounts of calcium salts break down on heating and form scale in boilers, pipes and cooking utensils. Magnesium — Magnesium is a common constituent of natural water. Magnesium and calcium ions are principal contributors to water hard- ness. Concentrations in excess of 125 mg/I can exert a cathartic and diuretic action. Sodium — Recommended limit not to exceed 20 mg/I. 1 Potassium — Potassium concentrations in drinking water seldom exceed 20. mg/l. Total Iron — Standard not to exceed 0.3 mg/I. Manganese — Standard not to exceed 0.05 mg/I.The principal reason for limiting the concentration of manganese is to reduce esthetic and economic problems. Silica — Silica content of natural water is most commonly in the 1 to 30 mg/I. Silica in water is undesirable because it forms difficult to remove silica scales. Sulfates — Standard not to exceed 250 mg/I. Chloride — Standard not to exceed 250 mg/l. Nitrogen — Ammonia is present in variable concentrations in many surface and ground waters. Its occurrence in ground water is generally a result of natural reduction processes. Nitrogen - Nitrite — Nitrite in water poses a health hazard, but fortunately seldom occurs in high concentrations. Waters with a nitrogen - nitrite concentration over 1 mg/I should not be used for infant feeding. Nitrogen - Nitrate — Standard not to exceed 10. mg/I. Nitrate, in high concentrations can and do cause methemoglobinemia or so-called nitrate poisoning in infants. Water with 10 or more mg/I of nitrate is unsatisfactory and is not considered safe for drinking or cook- ing. It is especially dangerous to children and should never be used in infant formulas. Copper — Standard not to exceed 1.0 mg/I. EDWARD E. KELLEY REG. LAND SURVEYOR CUMMAQUIDI MASS. 02637 TEL : (617) 362-2266 Town of Barnstable Dec. 30 , 1986 Board of Health Hyannis, Mass. Ref: 86-440 John Allegrini , Lot #2, Holly Hock Rd. , West Barnstable On. Nov. 17, 1986 we inspected the excavation to verify, a four foot layer of pervious material existed below the bottom of the leach pits. The leach pits, septic tank and distribution box were not installed at this time but the excavation conformed to the requirement -of Title V and the Town of Barnstable Health regulations. OF ol gsss tiP��� OF 44ss o EDWARD � ALL 2 t J KELLEY � eg° , ita Reg-: Pr-ofe s9i.onal Land �Su=rve."'ors a sanrtne�a� / y©aA L y.