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HomeMy WebLinkAbout0074 HOLWAY DRIVE - Health LA Holway Drive Barnstable = 136 034 F Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for.Voluntary Assessments r 74 Holway Drive Property Address � - John Kennefick Owner Owner's Name / information is West Barnstable Ma 02668 9/20/2018 ' required for every page. CitylTown State Zip Code Date of Inspection t=1 , 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 filing out forms A. Inspector Information �S 1338 9 on the computer, use only the tab Sean M. Jones key to move your Name of Inspector cursor-do not S.M.Jones Title V Septic Inspection use the return Company Name key. 74 Beldan Lane ,Q Company Address Centerville Ma 02632 Cityrrown State Zip Code 508-658-3456, 774-2484850 SI 4522 sean@smjonestitle5.com 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. [0 Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 9/20/2018 Inspector's Signature tarDate 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 6. 4 Commonwealth of Massachusetts I4p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments e 74 Holway Drive Property Address John Kennefick Owner Owner's Name information is required for every West Barnstable Ma 02668 9/20/2018 page. Cityrrown 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: ® 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 dwelling located at 74 Holway Dr West Barnstable is served by a Title V septic system consisting of a 1500 gallon septic tank, distribution box and 4 precast leaching galleys. The system was found to be in proper working condition at the time of inspection. 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 74 Holway Drive Property Address John Kennefick Owner Owner's Name information is required for every West Barnstable Ma 02668 9/20/2018 page. City/Town 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 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 Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 6 74 Holway Drive Property Address John Kennefick Owner Owner's Name information is required for every West Barnstable Ma 02668 9/20/2018 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: 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 16 Commonwealth of Massachusetts Title 5 Official Inspection Form l� p Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 74 Holway Drive Property Address John Kennefick Owner Owner's Name information is required for every West Barnstable Ma 02668 9/20/2018 page. Cityrrown 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 j 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 groundwater 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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 18 c� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments v% 74 Holway Drive Property Address John Kennefick Owner Owner's Name information is required for every West Barnstable Ma 02668 9/20/2018 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 74 HolwaY Drive Property Address John Kennefick Owner Owner's Name information is required for every West Barnstable Ma 02668 9/20/2018 page. City/Town State Zip Code Date of Inspection D. System Information 1. 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 gpd Description: Number of current residents: 0 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 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: vacant/unknownDate t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 74 Holway Drive Property Address John Kennefick Owner Owner's Name information is required for every West Barnstable Ma 02668 9/20/2018 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 at time of inspection Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1500 gallons How was quantity pumped determined? size of tank Reason for pumping: routine maintenance t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form ((c Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 4' 74 Holway Drive Property Address John Kennefick Owner Owner's Name information is required for every West Barnstable Ma 02668 9/20/2018 page. Cityrrown 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: system installed 1994 per town records Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 1.5 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Joints ok, no leaks or blockages. Vented through roof 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 74 Holway Drive Property AdJress John Keniefick Owner Owner's Name information is required for every West Barnstable Ma 02668 9/20/2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 1 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age --onfirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 gallons Sludge:depth: -- Distance from top of sludge to bottom of outlet tee or baffle Scum t-sickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? 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 was pumped for inspection and should be done again every 2 years for proper maintenance. Tank was structurally sound. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 f Commonwealth of Massachusetts 1e Title 5 Official Inspection Form �a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 74 Holway Drive Property Address John Kennefick Owner Owner's Name information is required for every West Barnstable Ma 02668 9/20/2018 page. Cityrrown 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.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 r Commonwealth of Massachusetts Title 5 Official Inspection Form < Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 74 Holway Drive Property Address John Kennefick Owner Owner's Name information is required for every West Barnstable Ma 02668 9/20/2018 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 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.): Distribution box was video inspected and found level and in good condition with no rot. Water level was even with outlet invert with no signs of past backup. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts ja ,z Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 74 Holway Drive Property Address John Kennefick Owner Owner's Name information is required for every West Barnstable Ma 02668 9/20/2018 page. Cityrrown 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: 4 ❑ 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 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 74 Holway Drive Property Address John Kennefick. Owner Owner's Name information is required for every West Barnstable Ma 02668 9/20/2018 page. 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.): s.a.s. consists of 4 precast galleys. Leaching facility should no signs of past hydraulic overloading. Soil and stone surrounding was dry with no indication of past saturation. 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.): t5insp.dac-rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 74 Holway Drive Property Address John Kennefick Owner Owner's Name information is required for every West Barnstable Ma 02668 9/20/2018 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): Materials of construction: Dimensions Depth of sollids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5nsp.dcc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form < Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 74 Holway Drive Property Address John Kennefick Owner Owner's Name information is required for every West Barnstable Ma 02668 9/20/2018 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 I of vZ t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 r Commonwealth of Massachusetts Title 5 Official Inspection Form l Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 74 HolwaY Drive Property Address John Kennefick Owner Owner's Name information is required for every West Barnstable Ma 02668 9/20/2018 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: 12'+ feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: 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: Groundwater elevation was established by accessing Town of Barnstable groundwater contour maps. 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 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 74 Holway Drive Property Address John Kennefick Owner Owner's Name information is required for every West Barnstable Ma 02668 9/20/2018 page. Cityrrown 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 t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 o s . CERTIFICATE OF ANALYSIS Barnstable County Health Laboratory (M-MA009) .9'rsn�rst•'�. Recipient: Joe Cosgrove Order No.: G18110313 William Raveis RE Report Dated: 10/09/2018 1 Mayflower Knoll Submitter: Joe Cosgrove, Realtor E Sandwich, MA 02537 Description: Lab Analysis Laboratory iD#: 18110313-01 Matrix: Water-Drinking Water Sample#: Sampled: 09/25/2018 9:55 By: Collection Addr: 74 Holway Dr.West Barnstable,MA Received: 09/25/2018 10:25 By: Ellie Sample Location: Turn Around: Standard Analyst: yn Method: EPA 524.2 Dilution: 1 Date Analyzed: 09/25/2018 @ 10:46 EPA 524,2- Volatile Organics by GC/MS Result MCL MIX Result MCL MIX Parameter ug/L ug/L ug/L Parameter ug/L. ug/L ug/L Dichlorodifluoromethane ND 0.50 Chloroethane ND 0.50 Chloromethane ND 0.50 Chloroform ND 80 0.50 Vinyl chloride ND 2.0 0.50 cis-1,2-Dichloroethene ND 70 0.50 Bromomethane ND 0.50 cis-1,3-Dichloropropene ND 0.50 1,1,1,2-Tebachloroethane ND 0.50 Dibromochloromethane ND 0.50 1,1,1-Trichloroethane ND 200 0.50 Dibromomethane ND 0.50 1,1,2,2-Tetrachloroethane ND 0.50 Ethlbenzene ND 700 0.50 1,1,2-Trichloroethane ND 5.0 0.50 Hexachlorobutadiene ND 0.50 1,1-Dichloroethane ND 0.50 Isopropyl benzene ND 0.50 1,1-Dichloroethene ND 7.0 0.50 Methylene chloride ND 5.0 0.50 1,1-Dichloropropene ND 0.50 Methyl-tert-butyl ether ND 0.50 1,2,3-Tdchlorobenzene ND 0.50 Naphthalene ND 0.50 1,2,3-Trichloropropane ND 0.50 n-Butylbenzene ND 0.50 1,2,4-Trichlorobenzene ND 70 0.50 n-Propylbenzene ND 0.50 1,2,4-Trimethylbenzene ND 0.50 p-Isopropyltoluene ND 0.50 1,2-Dibromo-3-chloropropane ND 0.50 sec-Butyl benzene ND 0.50 1,2-Dibromoethane(EDB) ND 0.50 Styrene ND 100 0.50 1,2-Dichlorobenzene ND 600 0.50 tert-Butyl benzene ND 0.50 1,2-Dichloroethane ND 5.0 0.50 Tetrachloroethene ND 5.0 0.50 1,2-Dichloropropane ND 0.50 Toluene ND 1000 0.50 1,3,5-Trimethylbenzene ND 0.50 Total xylenes ND 10000 0.50 1,3-Dichlorobenzene ND 0.50 trans-1,2-Dichloroethene ND 100 0.50 1,3-Dichloropropane ND 0.50 trans-1,3-Dichloropropene ND 0.50 1,4-Dichlorobenzene ND 5.0 0.50 Trichloroethene ND 5.0 0.50 i 2,2-Dichloropropane ND 0.50 ITrichlorofluoromethane ND 0.50 2-Chlorotoluene ND 0.50 Compound %Recovered QC Limits(%) 4-Chlorotoluene ND 0.50 1,2-Dichlorobenzene-d4 102% 70 130 Benzene ND 5.0 0.50 p_gromofluorobenzene 90% 70 130 Bromobenzene ND 0.50 Bromochloromethane ND 0.50 Bromodichloromethane ND 0.50 Bromoform ND 0.50 Carbon tetrachloride ND 5.0 0.50 Chlorobenzene ND 100 0.50 Attached please find the laboratory certified parameter list. Approved By:- (Lab Director) ND= None Detected RL = Reporting Limit + MCL Maximum Contaminant Level 3195 Main Street, P0. Box 427, Barnstable, MA 02630 Ph: 508-375-6605 Page 1 of 1 CERTIFICATE OF ANALYSIS ,$ 9 Barnstable County Health Laboratory (M-MA009) Recipient: Joe Cosgrove Order No.: G18110313 William Raveis RE Report Dated: 10/05/2018 1 Mayflower Knoll Submitter: Joe Cosgrove, Realtor E Sandwich, MA 02537 Description: Lab Analysis Laboratory ID#: 18110313-01 Matrix: Water-Drinking Water Sample#: Sampled: 09/25/2018 9:55 By: Collection Address: 74 Holway Dr.West Barnstable,MA Received: 09/25/2018 10:25 By: Ellie Sample Location: Turn Around: Standard Routine ITEM RESULT. UNITS RL MCL METHOD# ANALYST TESTED TIME Nitrate as Nitrogen 0.36 mg/L 0.10 10 EPA 300.0 LAP 09/25/2018 15:09 Copper ND mg/L 0.10 1.3 EPA 200.8 CL 09/27/2018 11:06 Iron 0.10 mg/L 0.10 0.3 EPA 200.8 CL 09/27/2018 11:06 pH 7.8 PH AT 25C NA 6.5-8.5 SM 4500-H-B DCB 09/25/2018 15:29 Sodium 8.9 mg/L 2.5 20 EPA 200.8 CL 09/27/2018 11:06 Total Coliform Absent P/A 0 0 SM 9223B RG 09/25/2018 15:37 Conductance 130 umohs/cm 2.0 EPA 120.1 DCB 09/25/2018 15:29 Water sample meets the recommended limits for drinking water of all the above tested parameters. Attached please find the laboratory certified parameter list. A Approved By: (Lab Manager) r I • ND=None Detected RL = Reporting Limit MCL=Maximum Contaminant Level 3195 Main Street, P0. Box 427, Barnstable, MA 02630 Ph: 508-375-6605 Page: 1 of 1 Commonwealth of Massachusetts /3 tp OJ? Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 74 Holway Drive n Property Address i+ Fay Kennefick CA Owner Owners Name information is required for every West Barnstable Ma 02668 9/24/2016 a page. Cityfrown State Zip Code Date of Inspection . C71 Inspection results must be submitted on this form. Inspection forms may not be altered in any, way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information Q on the computer, use only the tab 1. Inspector: key to more your cursor-do not Sean M. Jones use the return Name of Inspector key. S.M.Jones Title V Septic Inspection ray Company Name 74 Beldan Ln. Centerville Ma 02632 City/Town State Zip Code 774-2484850 smjonestitle5@gmail.com SI4522 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation b the Local Approving Authority 9/24/2016 Inspectors Signature Date ' The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 ,!( Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 74 Holway Drive Property Address Fay Kennefick Owner Owner's Name information is required for every West Barnstable Ma 02668 9/24/2016 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The dwelling located at 74 Holway Dr West Barnstable is served by a Title V septic system consisting of a 1500 gallon septic tank, distribution box and 4 precast galleys. The system was found to be in proper working condition at the time of inspection. i B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old"or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 74 Holway Drive Property Address Fay Kennefick Owner Owner's Name information is required for every west Barnstable Ma 02668 9/24/2016 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 74 Holway Drive Property Address Fay Kennefick Owner Owner's Name information is required for every West Barnstable Ma 02668 9/24/2016 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y day flow t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts Title 5. Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 74 Holway Drive Property Address Fay Kennefick Owner Owner's Name required fo is West Barnstable Ma 02668 9/24/2016 required for every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 74 Holway Drive Property Address Fay Kennefick Owner Owner's Name information is West Barnstable Ma 02668 9/24/2016 required for every page. Citylrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 gpd t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments wM 74 Holway Drive Property Address Fay Kennefick Owner Owner's Name information is required for every West Barnstable Ma 02668 9/24/2016 li page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (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 well 9 ( Y 9 (gp ))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: seasonal Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): gallons per day(gpd) E Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins 3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 74 Holway Drive Property Address Fay Kennefick Owner Owner's Name information is required for every West Barnstable Ma 02668 9/24/2016 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page S of 17 L — Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments b 74 HolwaY Drive Property Address P Fay Kennefick Owner Owner's Name requir t'onrequired is West Barnstable Ma 02668 9/24/2016 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: system installed 1/31/94 per town records Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1.5 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.): Joint were ok, no leaks, vented through the roof Septic Tank(locate on site plan): Depth below grade: 1 feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 gallons Sludge depth: 6" t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 r— Commonwealth of Massachusetts 4 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 74 Holway Drive Property Address Fay Kennefick Owner Owner's Name information is required For every West Barnstable Ma 02668 9/24/2016 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 3" Scum thickness 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 10" How were dimensions determined? opened covers, took measurements Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank does not need to be cleaned now but should be done soon and again every 2 years for proper maintenance. Water level was even with outlet invert, tank was not leaking and was structurally sound. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 74 Holway Drive Property Address Fay Kennefick Owner Owner's Name information is required for every West Barnstable Ma 02668 9/24/2016 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 74 Holway Drive Property Address Fay Kennefick Owner Owner's Name information is required for every West Barnstable Ma 02668 9/24/2016 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Distribution box was video inspected and found to be in good condition, no rot, water level was even with outlet invert. 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. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: ICI t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 74 Holway Drive Property Address Fay Kennefick Owner Owner's Name information is required for every West Barnstable Ma 02668 9/24/2016 page. CityrFown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ® leaching galleries number: 4 ❑ 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.): s.a.s. consists of 4 precast leaching galleys. No sign of past hydraulic overloading. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts OF Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 74 Holway Drive Property Address Fay Kennefick Owner Owner's Name information is required for every West Barnstable Ma 02668 9/24/2016 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3A 3 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 14 or 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 74 Holway Drive Property Address Fay Kennefick Owner Owner's Name information is required for every West Barnstable Ma 02668 9/24/2016 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately 71 F2 t t5 ns•3113 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 74 Holway Drive Property Address Fay Kennefick Owner Owner's Name information is required for every West Barnstable Ma 02668 9/24/2016 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 12'+ feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: 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: Groundwater elevation was determined by accessing Town of Barnstable groundwater contour map. Before filing this Inspection Report, please see Report Completeness Checklist on next.page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 74 Holway Drive Property Address Fay Kennefick Owner Owner's Name information is required for every West Barnstable Ma 02668 9/24/2016 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 F if CERTIFICATE OF ANALYSIS Pae: 1 of 1 Barnstable County Health Laboratory (M-MA009) m Report Prepared For: Report Dated: 9/6/2016 Maureen Reeve Order No.: G1696529 35 Indian Ln Franklin, MA 02038 Laboratory ID#: 1696529-01 Description: Water-Drinking water Sample#: Sample Location: 74 Holway Dr.W. Barnstable,MA Collected: 09/02/2016 Collected by: Customer Received: 09/02/2016 Test Parameters ITEM RESULT UNITS RL MCL METHOD# ANALYST TESp ED NOTE Total Coliform Absent P/A 0 0 SM9223 RG 9/2/2016 Water sample meets the recommended limits for drinking water of all the above tested parameters. M Attached please find the laboratory certified parameter list. Approved By: _ . (Lab Director) �0 ND=None Detected RL = Reporting Limit MCL=Maximum Contaminant Level 3195 Main Street, PO.Box 427, Barnstabie, MA 02630 Ph: 508-376-6605 CERTIFICATE OF ANALYSIS Page: 1 of 1 pY M, Barnstable County Health Laboratory (M-MA009) Report Prepared For: Report Dated: 09/01/2016 Maureen Reeve Order No.: G1696334 35:Indian Ln Franklin, MA 02038 Laboratory ID#: 1696334-01 Description: Water-Drinking.Water a Sample#: Sample Location: 74 Holway Dr.W Barnstable,MA Collected: 08/26/2016 Collected by: Customer Received: 08/26/2016 Routine ITEM RESULT UNITS RL MCL METHOD# ANALYST TESTED NOTE Nitrate as Nitrogen ND mg/L 0.01 10 EPA 300.0 LAP 08/27 21 016 Copper ND mg/L 0.10 1.3 SM 31116 LAP 08/3112016 Iron ND mg/L 0.10 0.3 SM 31116 LAP 08131J2016 pH 7_5 PH AT 25C I NA 6.5-8.5 SM 4500-H-B DCB 08126I/2016 Sodium 7.1 mg/L 2.5 20 SM 3111E LAP 08/3112016 f Total Coliform Present P/A 0 0 SM 9223 RG 081212016 Conductance 120 umohs/cm 2.0 EPA 120.1 DCB 08/2612016 Recommended maximum contamination level exceeded due to Coliform Bacteria. Tested negative for E.coli.Retesting is recommended. Attached please:find the laboratory certified parameter list. Approved By: (Lab Manager) f 1 k ND=None Detected RL = Reporting Limit MCL=Maximum Contaminant Lev,l 3195 Main Street, PO.Box 427, Barnstable, MA 02630 Ph:508-375-6605 ��RC a,Ry CERTIFICATE OF ANALYSIS Vry Barnstable County Health Laboratory (M-MA009) ..st r_rIVSI: }Recipient:- --_-^�-�Matrix: Water-Drinking Water -�--„ Maureen Reeve Sampled: 08/26/2016 35Indian Ln Received: 08/26/2016 14:16 Franklin, MA 02038 Collection Address: 74 Holway Dr.W Barnstable,MA j Sample Location: Order#: G1696334 Description: Lab Analysis Lab ID: 1696334 01 Date Analyzed: 08/26/2016 @ 10:10 Sample#: Analyst yn Method: EPA 524.2 Dilution Factor: 1 l Comment: Recommended maximum contamination level exceeded due to Coliform Bacteria.Tested negative for E.coli.Retesting is } recommended. EPA 524.2- Volatile Organics by GC/MS Result � MCL: MDL i Result 1 MCL MDL ` Parameter ug/L I ug/L I ug/L i Parameter ug/L I ug/Ll I ug/L Didtlorodifluoromethane ND I� 0.50 Chloro� form ND_ 80 f 0.50 1 ChloromethaneND _�_ .5o - - i as 1,2 Dichloroethene -T�ND - j 70 _0.50 :Vinyl chloride j ND 2.0 i oso las-1,3-Dichloropropene ND I ! 0.50 Bromomethane _ ND I 0.50 IDibromochloromethane 1 ND 0.50 :1 1 1 2 Tetrachlor-than --ND~ Di e !oe � bromom thane _ND0.50 - j1,1,1 Trichloroethane ND f zoo 1 0.50 Ethylbenzene I ND 200 0.50 I 11,_,2,2-Tetrachloroethane ! ND _ ( O.SD Hexachlorobutadiene _ I ND I 0.50_ I `____�_ j1,'+,2 Trichloroethane - ND _ 5.0 oso-�1lIsopropylbenzene ��_ -_� �ND I 1 r 0.50 I 11,1-Dichloroethane ND I 0.50 IiMethylene chloride { ND t 5.0 1 0.50 i 11,1-Dichloroethene y �_ ��- ND j 7.0 _! 0.50 EMethyl-tert-butyl ether _ _ ND A - 0.50 ii,i-Dichloropropene ND f 0.50 'naphthalene - ND II 0 .50 11,2,3-Trichlorobenzene ND j 0.50 i1n-Butylbenzene j ND 0.50 1 1,2,3-Trichloropropane i ND ( 4 5o i n-Propylbenzene ND , - ----_ !__� _. _.-fit _ ! {� 0.50 i i1,2,4-Trichlorobenzene - -i"'--ND 20 i o 50 IIp-Isopropyltoluene i ND ij 0s0-�1 `1,2,4 Trimethylbenzene ! ND + 0.50 Isec-Butyibenzene j ND ( 0.50 11,2-Dibromo-3-chloropropane 1 ND 0.50 Styrene ND 100 050 ' ND os0 p:e ND " 0.501,2-Dibromoethane(EDB> rt-Bu Ibenzene 1;2-Dichlorobenzene ND 1600 ' 0.50 I etrachloroethene ND 5.0 0.50 I1,22-Dichloroethane _ ND_ 5.0 0.50 IlToluene _ ND 1000 0.50 j1;2-Dichloropropane , i ND 1 0.50 J!Total xylenes - -ND {100001 0.50 1 I 11.3,5-Trimethylbenzene i ND 1 0.50 trans-1,2-Dichlbroethene ND ( 100 i= 0.50 11,3-Dichlorobenzene l ND_ _ 0.50 trans-1,3-_Dichloropropene I ND ! -0.50 • j1,3 Dichloropropane _ -_i ND �^ 4 0.50 -1,Trichloroethene- -ND TS.0 O.So 11,4-Dichlorobenzene I ND ! 5.0 0.50 lTrichlorofluoromethane�-T Fj- ND i i; 050 i2,2-Dichloropropane - ; �ND ! _ i 0.50 � - - -?%Recovered t QC Limits(%)j j2-Chlorotoluerie ; ND� i 0 Surrogates _i- Ip Bromofluorobenzene_ 89010 _ 1 700 1 J130 •1-Chlorotoluene ND I 0.50 - - I 1,2Dic- hlorobenze 4 86%.ne-d - 70 130 ; -- ---- _ _��-l_ 'Benzene __ ND ; 5.0 i oso EBromobenzene i - ND j 1 0.50 jBromochloromethane ND 0.50 ':Bromodichloromethane' ND i 0.50 i_.___ __._ _ w +Bromoform , i ND :Carbon tetrachloride I ND 5.0 1 0.50 I Chlorobenzene ND 100 1 o.so Chloroethane ND � ^-0.50 u Approved B .-. LQ_t_. Attached please find the laboratory certified parameter list. pp (Lab Director)) ND None Detected RL = Reporting Limit MCL Maximum Conta ninant Level 3195 Main Street, PO.Box 427, Barnstable,. MA 02630 Ph:508-375-6605 Page 1 of 1 COMMONWEALTH OF MASSACHUSETTS DEPARTMENT OF ENVIRONMENTAL PROTECTION Certified Parameter List as of:01 Juf 2016 M-MA009 BARNSTABLE COUNTY HEALTH&ENV DEPT,BARNSTABLE,MA Analvtes f Methods for NON-Potable Water Methods for Potable-Water ALUMINUM EPA 200.8 ANTIMONY EPA 200.8 EPA 200.8 ARSENIC EPA 200.8 EPA 200.8 BARIUM BERYLLIUM EPA 200.8 EPA 200.8 EPA 200.8 CADMIUM EPA 200.8 EPA 200.8 CHROMIUM EPA 200.8 EPA 200.8 COBALT EPA 200:8 COPPER EPA 200.8;SM 3111 S EPA 200.8;SM 311 IS IRON SM 31116 LEAD EPA 200.8 EPA 200.8 MANGANESE EPA 200.8;SM 31116 MERCURY EPA 200.8 NICKEL EPA 200.8;SM 3111 B EPA 200.8;SM 3111 B SELENIUM EPA 200.8 EPA 200:8 THALLIUM EPA 200.8 EPA 200.8 VANADIUM EPA 200.8 ZINC EPA 200.8;SM 31116 PH SM 4500-H-B SM 4500-H-8 SPECIFIC CONDUCTIVITY EPA 120.1;SM 2510B HARDNESS•(CAC03),TOTAL SM 23408 CALCIUM SM 31118 SM 31116 MAGNESIUM SM 3111E SODIUM SM 31116 SM 3111B POTASSIUM SM 3111B ALKANILITY;TOAL SM 23208 SM 23203 AMMONIA-N EPA 350.1 CHLORIDE EPA 300.0 CYANIDE,TOTAL EPA 335.4 EPA 335.4 FLUORIDE EPA 300.0 KJELDAHL-N EPA 351.2 SULFATE EPA 300.0 EPA 300.0 NITRATE-N EPA 300.0 EPA 300.0 NITRITE-N EPA 300.0 TURBIDITY EPA 180:1 TOTAL DISSOLVED SOLIDS SM 2540C SM 2540C NON-FILTERABLE RESIDUE(TSS) SM 2540D TOTAL ORGANIC CARBON SM 5310B CHEMICAL OXYGEN DEMAND HACH METHOD 8000 BIOCHEMICAL OXYGEN DEMAND SM 5210B TRIHALOMETHANES EPA 524.2 VOLATILE HALOCARBONS EPA 624 f VOLATILE AROMATICS EPA 624 VOLATILE ORGANIC COMPOUNDS EPA 524.2 PERCHLORATE EPA 314.0 HETEROTROPHIC PLATE COUNT SM 9215B TOTAL COLIFORM MF-SM 9222E TOTAL COLIFORM EPA 1604 TOTAL COLIFORM ENZ.SUB.SM 9223 FECAL COLIFORM MF-SM 9222D MF-SM 9222D E.COLI F EPA 1603 EPA 1604 E.COLI f EPA 1103.1 NA-MUG-SM9222G E.COLI MF-SM 9213D ENZ.SUB.SM 9223 ENTEROCOCCI EPA 1600 EPA 1600 Effective Date:01 July 2016_Expiration Date:30 Jun 2017 Page: 1 irk CERTIFICATE OF ANALYSIS Barnstable County Health Laboratory Report Prepared For: Report Dated: 09/30/2002 John Kennefick Order Number: G0217468 John Kennifick P O Box 849 W. Barnstable, MA 02668 Laboratory ID#: 0217468-01 Description: Water-Drinlung Water Sample#• 17468 Sampline Location: 74 Holway Drive,West Barnstable Collected: 09/20/2002 Collected by: John Kennefic 136-034 Received: 09/20/2002 Routine ITEM RESULT UNITS MCL Method# Tested LAB: IC Lab Nitrates <0.1 mg/L 10 EPA 300.0 09/20/2002 LAB: Metals . Copper 0.5 mg/L 1.3 SM 3111B 09/23/2002 Iron 0.1 mg/L 0.3 SM 3111B 09/23/2002 Sodium 9 mg/L 20 SM 3111B 09/23/2002 LAB:Microbiology Total Coliform Absent P/A Absent 307 09/19/2002 LAB: Physical Chemistry Conductance 118 umohs/cm EPA 120.1 09/23/2002 pH 7.6 pH-units EPA 150.1 09/23/2002 Note: Water sample meets the recommended limits for drinking water of all above tested parameters. Approved By: (Lab Director) 9/30Aoot. Superior Court House, PO. Box 427, Barnstable, MA 02630 Ph: 508-375-6605 TOWN OF BARNSTABLE LOCATION . '' Z�/` SEWAGE f0/0/ - VILLAGE SSOR'S MAP & LOT/✓,6�-- 3 INSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY:(type) (size) 1 i l NO. OF BEDROOMS_ PRIVAT WEL OR PUBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED: 1 DATE COMPLIANCE ISSUED: 1 �31 �( VARIANCE GRANTED: Yes No ���� ��� =�� . � _���, / � ���',�� Q� ��� ��� ^ A No.. . r _ . .. FEB..... ....... THE COMMONWEALTH OF MASSACHUSETTS FG 73 BOARD OF HEALTH TOWN OF BARNSTABLE Appliration for Disposal Works Tonotrnrtion Prrutit Application is hereby made for a Permit to Construct ( or Repairan Individual Sewage Disposal System at: tZIV - ..... ....._... ........ ................ ....... .... ....... ..... Location•Address or Lot No. .. r .* - -i r� .�.t ..---•------••------......•.... -!`�1w�. ? !4.... -�"�....irk......__. r...............r.S__%Z_ —,C- . Owner Address �F C 20 S-tt-/L� Lea- �- nls S ,-� �... ........ t`}--:��✓.......... ................................. Installer Address Type of Building Size Lot-_-----•----------_----_--•Sq. feet U Dwelling—No. of Bedrooms___________ ______________ ___ Expansion Attic ( ) Garbage Grinder ( ) '� Other—T e of Building .......... No. of persons............................ Showers — Cafeteria a' Other fixtures .__......_. W Design Flow.._.........«.................... gallons per person per day. Total daily flow__._.•.........._..._..................._gallons. WSeptic Tank—Liquid capacity/45-��___gallons Length_, ._ Width— ?.... Diameter---------------- Depth................ x Disposal Trench—No._1--------------- Width.....6.......... Total Length____________________ Total leaching area....................sq. ft. Seepage 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........................ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a •----------------------------------------- Description of Soil d - 5 ^--- -...------------4 .eft fi(-Tv l0 —.._...ltii V ......-•••-••--.-----•--•-•••--•---•----•-•-••---•-•--•-•••-•----•-••...............••-......•-•-••......-•-•--------------••-----------------•-•-----•--•--------------.........•--•-..........----•-•-- W UNature of Repairs or Alterations—Answer when applicable............................................................................................... --------------------------•---------------------•------------------------------------------------------------------•--------------------------•-----•--•-------•-•----------------------•---.._.....-•-- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed .--... �•- .�—� ------� Date Application Approved B PP PP y ---------------- ' -'-- '- " ? '. -. . Application Disapproved for the following reasons- -----------------------------------------------------------------'------------------------....------..........................'------ -------------------------------------........................................."--' '-"--------------_..-'--- --'-- -'---"'- --'--'---'--------'--------........."-'---- --'--"-..."'-'----- ---------------------------------------- Dne Permit No. 7. ... --_ � Issued ................................... Date f36- 63 THE COMMONWEALTH OF MASSACHUSETTS SG BOARD OF HEALTH TOWN OF BARNSTABLE AVVliraftou for Disposal Works Tonstrudinn rrrnti# Application is hereby made for a Permit to Construct ( to or Repair an Individual Sewage Disposal System at: L 07— Iat '7 y f-�u.J A.� '�i2lV C ...W�S�,' ................_-----_..........................•---•----•-••... •----•--•---•---------- --------••••-•-• .... ......................_.._............. •Location-Address or Lot No. ..... o i-N 10._...\L t_rJ IN.lr.r;! K'------------•------•----...... ..1 _►w� ?*d ----• 1. n��� --.... .............. .................... Owner Address a S . c ............. o sv— _38........20 rzfir• `'--........- +-1�.. --------------------------•---•-- Installer Address Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms........... ............................Expansion Attic ( ) Garbage Grinder ( ) `4 Other—T e of Building No. of persons............................ Showers — Cafeteria a' Other fixtures ....................... W Design Flow......._._��................. .gallons per person per day. Total daily flow_._..._.._��..._........_...._.._...._..gallons. WSeptic Tank—Liquid ca.pacityO.......gallons Length.6.:.��__ Width_ ��:'?._.. Diameter________________ Depth....._.......... x Disposal Trench—No....1---.-------•--- Width......8.......... Total Length----- -___. Total leaching area....................sq. ft. Seepage Pit No..................... Diameter..................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) � Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water•_-_--__----____-._____. f� Test Pit No. 2................minutes per inch Depth of Test Pit..............:..... Depth to ground water........................ a ................. •-----•-•-•-•••---•.........•--••-•-•-•-•--•---------------------------------------•------•....-•••----._....---•••......•-•-•-•--•-- Description of Soil s ............ /D...-••---•--G= err vLse..----------•----1...---......------n'- ...... U ..........................................................................................................................................................•..•--...............................----....._ f W ....................................................................................................................................................................................................... UNature of Repairs or Alterations—Answer when applicable............................................................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed .e.—✓� - � ....,---------------------- -------�t. -- -----Date -- Application Approved BY ---•---.......��rr�--.1- ,,".,-'- ----------------------------------------------..............................- ------E • � flare........:.. .... Application Disapproved for the following reasons: -------------------------------------------------------------------/.------------...........--- --- ........---...---...:........ ............................................................... .....--................................. Permit No. .................b IS Issued .. Date .. . Date ....-- THE COMMONWEALTH OF MASSACHUSETTS 4 BOARD OF HEALTH TOWN OF BARNSTABLE Cer#tftrate of C omplinure THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed or Repaired ( ) by f7\I, ..............Cod ........... ........................... Installer atL�� �- �.................. U Lw 1. •...---...----.. ....�....1.... 1. has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. ..-....?,;?,— ... dated . ..-�..? . ..... ...�9... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. �� �— DATE-----l ....;3- ...................----------..-. Inspector ..4,." . -7-.-... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE No....1.k.;? FEE... .%? .......... Disposal Works Tun#rur#iun f rrntit Permission is hereby granted....... •---•-• :: to Construct ( or Repair ( ) an Individual Sewage Disposal System at No..�7....._.Y! _ ..........�'-snv r............. ... ............................... Street as shown on the application for Disposal Works Construction Permit No,��O Dated.......................................... �� /J...................................... Board of Health DATE........ �--�•-•- FORM 36508 HOBBS R WARREN,INC..PUBLISHERS A" Fee ' - No- -_"__ ----------- BOARD OF HEALTH r TOWN OF BARNSTABLE ZIpplitation_*rVell Con5tructionpermit Application is hereby made for a permit to Construct ( ), Alter ( ), or Repair ( )an irldiviccliq Well at: Location — Aodresi Assessors Map and Parcel owner Address 5 — — W----—-----------------—------------------ ---------------------—-------------------------— -- Installer — Driller Address _ Type of Building Dwelling---------— — -— --- -- Other - Type of Building No. of Persons------------------------------------------ -- c t Type of Well— � k� --- -- V��-------- Capacity—— — — -- --— ——__ — Purposeof Well-------------------------------------------------------- Agreement: The 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 Certificate of Compliance ha been issued by the Board of Health. Signe - - - - - --— — Q date Application Approved By -- - - —---— -- date Application Disapproved for the following —_---- -- ---- -- -— --—----------- _---- - ---—---------—__ __ date Permit No. — --—- Issued------------------------------------------------------ —---- date BOARD OF HEALTH TOWN OF BARNSTABLE (Certificate Of 'Compliance THIS I TO CERTIFY, t the Individual Well Constructed ( ), ltered ( ), or Repaired ( ) byate'-"�`—"—- -- ---- - -- --------- ------------------------ aller l�st — at-��_L_ -- Q ♦�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--_- =—;— —---——-- --- —— I (7) N -- u . J1 .6MY -----I o '_1- a ----- � .. »,. Fee --- y t f i t� BOARD OF HEALTH -TOWN OF tBARNSTABLE Appritat ion Arlefl Con5truttion3permit Application is hereby made for a permit to.Construct ( ), Alter ( ), or Repair ( )an individu Well at: - - --------` ------ -- ------------ ---luly P j 36 -- Location — Address Assessors Map and Parcel _ 1 -'- -c� D•� -— --__-------------------------------------------------------------------- Owner " Address — — — -- — — --— -- — ---------------------------------- Installer — Driller Address Type of Building Dwelling------------------------------------------------------------- Other - Type of Building-------------------------------- No. of Persons----------------------------------------------------- tr I Type of Well- ------�'-- lF -------- Capacity------------- --------------- -- " i Purposeof Well-------------------------------------------------------------------- Agreement: The 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 Certificate of Compliance-has been issued by the Board of Health. 1 —---- — --Signed- date=--------------------------- �_--��- -- -----t^--- l/ Application Approved BY- --------------------—--------- date i Application Disapproved for the following reasons:---------------------__------ --------------------------------- - -------------- - =----------- --— =------------------------------------------ ------------- date .� ---------------------- Issued----------------------==------d e - -Permit No. --- — -- - ---------- ------ - - - --- ------------------------- � date a BOARD OF HEALTH TORN ��0 '. ..BARNISTABLE Certificate Of Compliance - �- THIS IS TO CERTIFY, hit the Individual Well Constructed ( ), ltered ( ), or Repaired ( ) ----- ---------- by—(� � Installer 'i k a � �'— ---------------- � - - - -t 1- i 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 'Z Derr Con0ruct ion 3permit 2 � No. ------------------- Fee------------------- C It i Per4in hereby granted ;� -- - - -- - - - to Cons Alte��}( ), o Re air ( )/�a /Indivild�ua Well at y� /No. ----- ---/ ! L`1_Y ,1-� � - -( — _1 - -'_'L 0r-----� =-� �/V — 1 — Street j as shown n the a plicati f Well Construction Permit - -------- s - j � i Board of Health 1 DATE --_- ---- -------- -- --------------------------- - �T � r ---- --------------- _ FEE \ 69 + ` /• o` 7pAj r ►o Z FEEL l �o_+ . �'��'�:-'r*q'�3t�+�F3t� � �•,• � e- r+.+ \ s �.r+ � Y •. .. - ._ An --- NT go /� ¢ \ 44.4 ToPcF rZo. S4.cr _ �----T , r tee - 'Y ` ��'f ` � jam\ 4. ��••. � r •.'�•- a ,' 1'•Z:. r ` v •' , Ser 3 �ar a' ,, ,/ +y sJ•\0 �, Q c P �� r,�t, `t' a..• "t _ i `...'.. _'f4.,. _ r .+... y. •'A..-.�s. r„� .� �-�� `�4 +4�•Wrt+, v pis- �4 4^,v. x,� �NVIROTECH LABORATORIES Mass. Cert.#:MA063 1 449 Route 130 Sandwich,MA 02563 - (508) 888-6460 CLIENT: John: Kennefick LOCATION: Lot 19 Holway Drive ADDRESS: Winchester, MA Barnstable, MA COLLEC-TED BY. Desmond Well SAMPLE DATE:11-8893 TIME:2:OOPM DATE RECEIVED:11-8-93 SAMPLE ID:827 JOB#: New well WELLDEPTH: 85'/26' RESULTS OF ANALYSIS: Parameter Units Recommended limit Result Coliform bacteria/100 ml (MF Method) 0 0 pH pH units 6.0-8.5 7.24 Conductance umhos/cm 500 120 Sodium mg/L 28.0 9.1 Nitrate-N mg/L 10.0 0.02 Iron mg/L 0.3 0.16 Manganese mg/L 0.05 Hardness mg/L as CaCO3 500 Sulfate mg/L 250 Potassium mg/L 20.0 Alkalinity mg/L 200 Chloride mg/L 250 Turbidity NTU 5.0 Color APC units 15.0 Background bacteria/100 ml (MF method) 200 " EPA 601/602 * ug/L N.D. COMMENT• # See report attached. YES NO EfixS WATER IS SUITABLE FOR DRINKING PURPOSES FOR P RS TESTED. d1..` DATE (4"k t GROUNDWATER ANALYTICAL EPA METHODS 601 and 602 Volatile Organics (GC/PID/ELCD) Field ID: 827 Lab ID: 6369-01 Project: Kennefick 19 Holway Batch ID: VG2-0266-W Client: Envirotech Sampled: 11-08-93 Cont/Prsv: 40mL VOA Vial/NaHSO4 Cool Received: 11-10-93 Matrix: Aqueous Analyzed: 11-12-93 PARAMETER CONCENTRATION REPORTING LIMIT (ug/L) (ug/L) Dichlorodifluoromethane BRL 5 Chloromethane BRL 5 Vinyl Chloride BRL 5 Bromomethane BRL 5 Chloroethane BRL 5 Trichlorofluoromethane BRL 1 1,1-Dichloroethene BRL 1 Methylene Chloride BRL 1 trans-1,2-Dichloroethene BRL 1 1,1-Dichloroethane BRL 1 cis-1,2-Dichloroethene * BRL 1 Chloroform BRL 1 1,1,1-Trichloroethane BRL 1 Carbon Tetrachloride BRL 1 Benzene BRL 1 1,2-Dichloroethane BRL 1 Trichloroethene BRL 1 1,2-Dichloropropane BRL 1 Bromodichloromethane BRL 1 2-Chloroethyl Vinyl Ether BRL 5 cis-1,3-Dichloropropene BRL 1 Toluene BRL 1 trans-1,3-Dichloropropene BRL 1 1,1,2-Trichloroethane BRL 1 Tetrachloroethene BRL 1 Dibromochloromethane BRL 1 Chlorobenzene BRL 1 Ethylbenzene BRL 1 meta-and para-Xylene * BRL i ortho-Xylene * BRL 1 Bromoform BRL 1 -1,1,2,2-Tetrachloroethane BRL 1 1,3-Dichlorobenzene BRL 1 1,4-Dichlorobenzene BRL 1 1,2-Dichlorobenzene BRL 1 QC SURROGATE COMPOUND SPIKED MEASURED RECOVERY QC LIMITS. a,a,a-Trifluorotoluene 30 31 105 % 87 - 113 1,2-Dichloroethane-d4 30 29 97 % 83 - 117 BRL = Below Reporting Limit. * Non-target compound. Method References: Method 601 - Purgeable Halocarbons and Method 602 - Purgeable Aromatics, 40 C.F.R. 136, Appendix A (1986). r, 3 ~' Department of Environmental Management/Division of Water Resources a i WELL COMPLETION REPORT WELL LOCATION GEOGRAPHIC DESCRIPTION Address 40 T N S E W, of /,, (leer) (circle) City/Toyyr GfJ. ,4XA/J/J_,46-C C' Well owner 'T I�ENN��� !road/ Address /i.y.ySo/yo �,tr _- _ N .S E W of (nil.in renthsl (clrclel Board of Health permit obtained: /Y yes ❑ no El (road) w/ (road) WELL USE," WELL DATA p Domesti( [t�Public❑ Industrial E] Total well depth 4 S ft. II, Monit4ing❑ Other Depth to bedrock ft. 4 y Water-bearing rock/unconsolidated material: Method drilled S pUc7P/� 93 Description Date drilled Water-bearing zones: CASING / 1) From To Type 1�C-..� 'Ya p' 21 From To Length�ft: DiaLI.D.) _in. 3) From To Length into bedrock ft. �. Protective well seal: Gravel pack well: dia. Screen: dia. Grout-El Other Slot"i—Alr—, length_4!�__1from_&LtoZs—' pSTATIC WATER LEVEL(all wells) Static water level below Land surface— _ft. Date WELL TEST(production wells) Drawdown 4 ft, aftor pumping_shr.A0 min.at ,ZF gpm How measured oiRecovery f't. a4'tel!�--1tr. - min. a LOG.of FORMATIONS COMMENTS 'Materials Front To - - 0. Cj'. r 9irwve Driller imrl�GL. fermi .� i[ Firm /�•/Jic. ,�.�crnJ ��iGG�n/� Address "AMMIM F/77`) SANs1}�. t City/Town p/o�4t Supervising Driller Reg.# �3 Sign. j pervisin registered well driller - Pleeseprinrtvmly BOARD. OF HEALTH COPY 5M►df "C Mf 6 Locos MA'? lr -.iU �.. - 25, 1 �Y 3 -- - -- �.. 1��d - y L�T t� 4s . . ra_ 44. ----- — �o s 44 LoT 20 r 44.4 k5a o � / = T. kN f -! i r S `,`, ••; /fie/ � �`��� 1 / / 67 cB ter, d �✓f F� . f� . S)NGL_E FA�'I!Cy ---- 4- Leu)t2-ccori5 No -SE-T-- _I c TA1)K. = 44-o x. iSo7 _ 660 G.P D ,fl. yap. U 5 E t 5'0 o &A L. TA or-- D ►spo SA t�i L > ULE. (4) 4-"'c¢' CAL,L9 w.�r� ?rsT�v�` � � TE PLA\ I l 20 S1DCWA LL. A?-�A = 2 2 4 s. 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