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Home My WebLink About0145 KETTLEHOLE ROAD - Health %i45 Kettlehole Road West Barnstable A = 109 - 058 I TOWN OF BARN TABLE LOCATION SEWAGE# /// 0 ,-0 VILLAGE D �lJ, SSE`SSO_R'S MAP&PARCEL i-»� AME&PHONE NO. �G I � STi�. L LAS"—S30 7 SEPTIC TANK CAPACITY C,C LEACHING FACILITY:(- T I^ (size) Ip �- S'10 Vl e NO.OF BEDROOMS OWNER 7bMIC`i1SO to PERMIT DATE: 03 (Q 3 (O-� COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility.(If any wells exist on'site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) ff Feet ar� FURNISHED BYiQ¢ f "� � Sh i� er f. o d u O L-s/\ Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 'w 145 Kettlehole Road Property Address Neale Tomkinson Owner Owner's Name information is required for W Barnstable Ma. 02668 3/09/2007 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:When filling out A. General Information 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 r� P.O.Box 763 Company Address Centerville Ma. 02632 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 to Section 15.340 of Title 5(310 CMR 15.000):The system: ® Passes ❑ Conditionally Passes ❑ Fails ` 1 ❑ Needs Further Eva uation by the Local Approving Authority 3/09/2007 'u w Inspector's Signature Date ' r The system inspector shall submit a copy of this inspection report to the Approv ng Authority(Board of Health or DEP)within.30 days of completing this inspection. If the system is .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. 145 kettlehole rd.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 145 Kettlehole Road Property Address Neale Tomkinson Owner Owner's Name information is required for W Barnstable Ma. 02668 3/09/2007 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: ❑ 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 145 kettlehole rd.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,^M 145 Kettlehole Road Property Address Neale Tomkinson Owner Owner's Name information is required for W.Barnstable Ma. 02668• 3/09/2007 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ 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. 145 kettlehole rd.•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 145 Kettlehole Road Property Address Neale Tomkinson Owner Owner's Name information is required for W Barnstable Ma. 02668 3/09/2007 every page. City/Tow.n 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 Y2 day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. 145 kettlehole rd.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 15 I I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 145 Kettlehole Road Property Address Neale Tomkinson Owner Owner's Name information is required for W Barnstable Ma. 02668 3/09/2007 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. 145 kettlehole rd.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 145 Kettlehole Road Property Address Neale Tomkinson Owner Owner's Name information is required for W Barnstable Ma. 02668 3/09/2007 every page. City[Town State Zip Code Date of Inspection C. Checklist Check if the following have been done.You must indicate"yes" or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® El available 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)] 145 kettlehole rd.•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 cM 145 Kettlehole Road Property Address Neale Tomkinson Owner Owner's Name information is required for W Barnstable Ma. 02668 3/09/2007 every page. City/Town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 04 Number of bedrooms (actual): 04 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 Number of current residents: 2 Does residence have a garbage grinder? ® Yes ❑ No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ® Yes ❑ No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage (gpd)): Well Water 9 ( Y 9 Sump pump? ❑ Yes ® No Last date of occupancy: 03/09/2007 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): 145 kettlehole rd.•08106 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 145 Kettlehole Road Property Address Neale Tomkinson Owner Owner's Name information is required for W Barnstable Ma. 02668 3/09/2007 every page. City/Town State Zip Code Date of Inspection D. System Information cont. General Information Pumping Records: Source of information: Capewide Enterprises,LLC Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume-pumped: 1000 gallons How was quantity pumped determined? Measured Reason for pumping: Maintenance Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: 1984 Were sewage odors detected when arriving at the site? ❑ Yes ® No 145 kettlehole rd.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 145 Kettlehole Road Property Address Neale Tomkinson Owner Owner's Name information is required for W Barnstable Ma. 02668 3/09/2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): i Depth below grade: 2' feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: 150 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): Depth below grade: 26"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: 8'6"x4'10"x57' Sludge depth: none Distance from top of sludge to bottom of outlet tee or baffle na Scum thickness none Distance from top of scum to top of outlet tee or baffle na Distance from bottom of scum to bottom of outlet tee or baffle na How were dimensions determined? Pumped tank at inspection 145 ketllehole rd.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 145 Kettlehole Road Property Address Neale Tomkinson Owner Owner's Name information is required for W Barnstable Ma. 02668 3/09/2007 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 septic tank every 2-3 years.lnlet and outlet tees are in place.No evidence of Ieakage.Tank appears 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 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): 145 kettlehole rd.-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 145 Kettlehole Road Property Address Neale Tomkinson Owner Owner's Name information is W Barnstable Ma. 02668 3/09/2007 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 has two 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 145 kettlehole rd.-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °wM 145 Kettlehole Road Property Address Neale Tomkinson Owner Owner's Name information is required for W Barnstable Ma. 02668 3/09/2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 02 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Sandy soil.No signs of hydraulic failure.Vegetation appears normal.Leaching pits water to invert was 36" at time of inspection. 145 kettlehole rd.-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °w 145 Kettlehole Road Property Address Neale Tomkinson Owner Owner's Name information is required for W Barnstable Ma. 02668 3/09/2007 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.): i 145 kettlehole rd.-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 Commonwealth of Massachusetts a W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments �M 145 Kettlehole Road Property Address Neale Tomkinson Owner Owner's Name information is required for W Barnstable Ma. 02668 3/09/2007 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 supply enters the building. ox -3�_ Freon l aq� a , m 5 145 kettlehole rd.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15 ` Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 145 Kettlehole Road Property Address Neale Tomkinson Owner Owner's Name information is required for W Barnstable Ma. 02668 3/09/2007 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: 80' 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 observation well data June 1992.Used: Technical bulletin 92-000-01 plate#2 annual ranges of ground water elevations 145 kettlehole rd.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 ••.+..uva%,L,4 Y"AL•111 OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL DEPARTMENT OF ENVIRONMENTAL PI;AFFAIRS OTECTION �� q/07 �� aS'•`t�� TITLE 5 � 1 OFFICIAL ]NSPECTION FORM NOT FOR VO SUBSURFACE SEWAGE DISPOSAL,g STEM ASSESSMENTS PART A CERTIFICATION Property Address: L l e 2J . LA'I 'I Owner's Name: Owner's Address: i Date of isapeetioa• Name of Inspector• 1 p . Q Company Name; f Mailing Address: Telephone 0 CERTIFICATION STATEMENT I cer*that I have paw=Uy inspected the sews ge below is true,accurate and complete as of the time of disposal system at this address and that the information �8 proper function and mapectio on a The ' performed based on ray rted approved system j pectorr p�aut to section 1S34 nancO of sloe��osd systems.I am a D1IP ( 0 CMR 15.006). The System Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fa>ys Inspector's Signatar : Date: C)11CL31 eo The system inspector shall submit a copy of this DEP)within 30 days of completing this • inspection report to the Approving Authority(Board of Health or gpd or greater,the ' inspection.If the system is a shared system or has a design flow of 10,000 MA The Originalinspector and the system owner shall submit the report to the r should be sent to the system owner and copies sent to the buy applicable, �ae r the authority. PPmvmg Notes and Comments I ti�(' �1 C ` 1 Oft S �- 6 v S 1 h-con j"S��h� ` �v� � � Uv Y-\e ;,.,Th 0 t l is report only describes conditions at the time of Inspection time:This Inspection does not address how the system wil perform Lathe future u d�under the i conditions same f eat that conditions of use. me or different Title 5 Inspection Form 6/15/2000 page I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTIONFORRM PART A CERTIFICATION(continued) Property Address: Owners Date of Inapeetioas Inspection Summary: Check AAC,D or E/A ]MS complete A of Sudan D A. System Passes. I have not formd any information which indicatesthat myof 3.303 or in 310 CMR 13.304 exist.Any failuro criteria �the mQ�M d dbed in 310 CMR indicated below. Coe ell c e C\Ij ecti ,` ev� 2- B. System Conditionally Passes: or more system components as described in the"Conditional Pals» laced or Van completion of the replacement ar�,as �need to tk Win Pans. � Yee,no or explain. letermined(Y.N.ND)in the for the following statements.If-not determined"please 710 septic tank i,metal over 20 years old*or the septic tank unaormd,exhibits substantial infil n or ex8ltration or tank��is (whether )is strnetmaIIy, *existing tank is replaced with a comp septic tank as by� of win pass won if the A MOW septic tank will pass inspection' Health. indicating that the tank is ICU than 20 years old sow'not and if a Certificate of Compliance ND explain: Observation of sewage backup or b ut or hi ggh obstructed pipe(s)or due to a broken, or ass water level in the distribution box due to broken or approval of Board of Health): uneven distrrbuti System will ass P inspection if(with broken Pipes)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The ystem required PumPing more than 4 times a year due to broken or obstructe ipe(s).The system will P on if(with approval of the Board of Health): broken pipes)are replaced obstruction is removed ND explain: Tills i inon�.tin.. Rnrm All cnnnn 2 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENT'S SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 1'-1 S Le 1 1 e Owner: � Date of Inspeetlon; - C. Further Evaluation is Required by the Board of Health: cc &bn exist which rogM iiudw evaluation by the Board of Health in order to determdns If the system is failing b tect public health,ssfety or the environment L System ill pass unless Board of Health determines In accordance with 310 CMIR 13.3 1 system Intlnnedening in a manner which will protect public bukk safety and the eavirob)that men ut:the _ cesspoo Privy is within 50 feet of a Suaribee water _ Cesspool is within 50 feet of a bordering vegetated wedand or a h Z. system will fall Unless the rd of Health(and Public We system le ttimcdoning Ina manner t protects the public h S u yP 'Ifand any) dart: nes that the _ The system has a septic talc it absorption (SAS)and the SAS is within 100 feet of a surface water supply or tn'butary to a e water y, _ The system has a septic tank and SAS the is within a Zone 1 of a public water supply. _ The system has a septic tank and SAS and SAS is within SO feet of a private water supply well. The system has a septic tank and SAS the is less than 100 feet but 50 feat or most:from a private water supply well**.Method to deterrniae e •'This system passes if the weU wa analysis performed a DEP certified unborn bacteria wad volatile tory,for coliform organic umds indicates that the we is free f m polhWon from that facility and the presence of ammonia nitro and nitrate nitrogen is equal or less than S Pp�provided that no other fad=criteria are triggered, copy of the analysis moat be attar to this form 3. Other: Till- 4 l—a-'in" P—xil C/7nnn 3 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Owner: Date of Iwpeegoa: —� D. System Fallen Criteria appncable to an ayatemr. You am indicate"yea"or"no"to each of do following for gL one: Yea No _--_ -4 Backup of sewage into facility or system co 1/ Dirge or ponding of ofHuent to the sur�oSmP°now due to overloaded of clogged SAS of cesspool ./ clogged SAS or cesspool ground or surfics waters due to an overloaded or Staa�level m the distribution box above outlet invert due to an overloaded or clogged SAS or Liquid RequinM Pumpingdepth is spool is less than 6"below invert or available vohnae is lea �J �of dmss p y fiow, move than 4 times is the Last year j jQ,Zdhe to clogged or ohs )•riva�ber .� Any Pad=Any POba of the SAS cesspool or privy is below high ground water elevatiao. watersuPply.of cro �Of privy is within 100 lbet of a sm$ce water supply or tribe J tary to a sur$ce Any pa tdon of a cesspool or privy is within a Zone 1 of a public wen. j — Any pmdon of a cesspool or privy is within SO f private eet ota private water-- �►ny portion of a cesspool or privy i•lea thaw 100 feat but °Mb'wen' systosupply wen with no greater than SO feet from a water Performed at s D eergfled lobos or orm�b m paw uthe w water anab'ak Indlesta that the wall is fm&am aeterla and volatlle organk compounds nitrogoa and dtrab d °tlO°d'°m that tadllty and the presence of anmanla are tsi copy man 6 equal u or lea than S to ft laded that no other failure criterla lam•A� of the ansb+ds meat be attached to this torm.j (Ye*Wo systedescribed in 0m bb I have determined that one or failure CI�IIt 15.303,therefore the �'e of the above criteria exist as Health to determine what will be � '�e sum° should contact the Board of necessary to correct the failrm Z. Large Systems: To considered a large system the system must serve a fadHty wi t� th a design now of 10,000 gpd to 15,000 You must sate either"yes"Of"no"to each of the following; (The following apply to large systems in addition to the criteria above) yes no — the system is within 4 of a surface drinking water supply _ — the system is within 200 feet of a trib to a surface water supply — — the system is located in a nitrogen sensitive Zone U of a public water supply well Wellhead Protection Area—IWA)or a mapped If you have answered"yea"to any on in Section E the system is consi "Yes"is Section D above the a system has failed.Thu owner or operator of an significant threat,or answered significant threat under lion E or failed under Section D shall u y system considered a 15.304.The syste weer should contact the a upgrade�system in� e with 310 CM appropriate regional Office of the Department. TiN� In.na�►inn Rnnn 4/1 gnnnn 4 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: Owner: ' C — Date of Inapecdon: 1 Check if the following have been done.You must indicate "or"no"as to each of the fol>owin Ygs No J ._. Pu PUIS information was provided by the owner.occupant;or Board of Health J Were any►of the system components punved out is the prrvious two weeks? _ Has the system received normal t!ova in the p vvioug two week period? _ Have large vollmus 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 MA) _ Was the facility or dwelling inspected for sign.of sewage back up? �.L _ Was the site inspected for signs of break out? _ Were all system components,excluding the SAS,located on site? J _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected of the battles or tees,material of construction,dimensions,depth of ligtdd,depth of slud for the condition sludge depth of scum? _ Was the&cihty owner(and occupants if di8'erent from maintenance of subsurface sewage disposal systems? own")provided with information on the proper The size and location of the Soll Absorption System(SAS)on the site has been determined based on: Y no _ Existing information.For example,a plea at the Board of Health. J _ Determined is the field(if any of the failure criteria related to part C is at issue approximation of is maccepmble)P 10 CMR 15.302(3)(b)] distance T41,It fnon&o►inn re%rm IG/1 C/7/1(1/1 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: JLC 4\! ho�e.l- . Owner. Date of Inspeetlons O FLOW CONDPPIONS RESIDENPlAL Number of bedroom.(design):4 Number of bedrooms(actual): LA DBSI(lbi Row based an 310 0q 15.203(for example: 110 gpd x M of bedrooms) Number of currrcat rwidentaG Dow reaidenoe have a garbage grinder(Yea or no):UL is laundry on a separate sewage system(yes or no):LD[if ya separate inspection mquir+ed) Lanodry system Inspected(yes no)i2a Seasonal use:(yea a no) • l� Water meter readmga,if a le(last 2 years usage(gpp:- � �A Sump pump(yes or no): " Last date ofaccupan�y: p_ yY SQY\'} t �\)t co lU$—TRIALWr,de 1O J� z6s. Type ofeata"Likuft =P' sed 310 CUR13.203):of design i�v eata/petsans/sgt�etc.): praft(yea industriaGrew l bodIdinS tan or no): Non-sanitary wute discharged to the Title a or no):_ Water meter readings,if available: Last date ofoccupancy/uae• OTHER( ): Pumping Records GENERAL INFORMATION Source of information; Was system pumped as part of the inspection(yea or no):_ If yea,volume pumped:_,gallons—How was quantity pumped determined? Reason for pumping: TKPE OF SYSTEM J Septic tank,distribution box,soil absorption system 2 _Single cesspool _Overflow cesspool —Privy _Shand system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Mternative 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 conwo nta,date installed(if Imown)and source of information: 1 - Were sewage odors detected when arriving at the site(yes or no): f� Ti►i,a C Tnenar►inn T:nrn,4/1 C/'fAAA 6 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: )Ll S owner: QKy*- �S Date of Inspection: 3 a1 BUELDING SEWER(locate on site plan) 1� Depth below grade: i Z_ _l�, Materials of construction: cast irosa L4o PVC_other(eriphria): Distance Flom private water supply well or suction line: vJ Com ema(on}condi *on ovf Join%vendnL evidence of le g0. 1 oIC- SEPTIC TANKS_(locate on site plan) 11 %I Depth below grade: 'b'4 . Material of constructl-on-concrete_metal_Sbezglass___polyethylene other(owlak) If tank is metal list age:_ L age confirmed by a Cart eats of Compliance(yes or no):_(attach a copy of Dimendom: � 100 4Gc, Sludge depdL- Distim Dom top of sludge to tiom of outlet tee or baffle: Scum thickness : 12tAC l2 DLtsnce flom top f scum to top of outlet tee or baffle: Distance flnom bottom of scum to bottom of outlet tee or baffle: 1 \=1Z How were dimensions determined: ,'a r-L)b le-0 Comments(an pumping recommendations,inlet and outlet tee or baffle condition,structural into as related outlFt� of leakage,etc.): integrity,liquid levels �- l , �S ,x �✓`� �f GREASE TRAP:(locate on site plan) Depth be _ Material of construe concrete_metal_Mmfglass__polyethylene�othet�" (evlain): ��. Dimensions: Scum thicimesa: Distance from top o top of outlet tee e: Distance from bottom of scum to bo o outlet tee or baffle: Date of last pumping: Comments(on recommendations,inlet and outlet tee or baffle condition,strut as related to et invert,evidence of leakage,etc.): tY,liquid levels Title C fnononfinn Rnnn IG 7 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART SYSTEM INFORMATION(continued) Property Address: Owner. Date of Iaapeedons A TIGHT or HOLDING TANK: (tank must be rmped at time of inspection)(locate on site plan) Depth butwial of concrete metal fiberglass__polyethylene otber(explain Dimensions: oali~ Design Flow. as<llow'day Alarm presem(yes or no): Alan level• Al order(yes or no): Date of last cmmem 'lion of alarm and float switches,etc.): DISTRIBUTION BOX: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert l9 Conaauents(note if box is level and distni ion to outlets equal,any evidence of solids carryover,any evidence of lealcaim into�OF out ofbox,�etc.): h a PUMP CHAMBER (locate on site plan) Pumps in working o Alarms in working order(yes or no): Comments(note condition of �,con"diaon— and appurtenance,etc.): TWo I /nonn�tinn Rnrn,A/1;/7njW% 8 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Plop"Address, l N S 120 . Owner: To o ri Date of don:InsPec n• "1 SOIL ABSORPTION SYSTEM(SAS): (beats on site plan,excavation not required) USAS not located explain why: �rlea pits mnnber:_z k 0 0 o do c--% � 7L to Jk 3 /S+v r\e- leaching chamb %number: Teaching galleries,number.: leaching tm=hM number,length: leaching fields,number,dimensions: overflow cesspool,number: innovativela ternative system Typehume of technology: Comment(note condition of soil,signs of hydraulic fide%level of11 _ etc.): _ P damp soil,condition of vegetation, 1,-C— $rp— , CESSPOOLS: (cesspool mist be pumped as part of b"PectionVocate on site plan) M configuration: Depth— liquid bidet invert Depth of solids Depth of seam layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or Comment(note condition of soil,signs of by failure, of ponding,condition of vegetation,etc.): PRIVY: (locate on site pi Materials of construc Dimensions. Depth of so ' : Co (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): TWA i lnonar►inn Annw!/1 9 Page 10 of l l ' OFFICIAL xNsPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DLSPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(canonucd) PropeM Address: Owner: Tb 0 Date of Iaspectbs: 1 SI�TCS OF SEWAGI DESPOSAL SYSTEM Provide a sketch of ew sewage disposal symem iocludiog ties to at least two permanent rdweace loadmarb or benchmarks.I all wells within 100 feet Locate Am public water supply ehmers the budding. f 5 1 o' D n � -To UriJev te��l 0 in r �. OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: -1 L " 'V{- L RZ- Owaen Data of Inspection: -1 SITZ FRAM Slope Surface water Check cellar Shallow wells Estimated depth to groundwater 2 0{feet Please b dkate(check)all methods used to determine the high grand water elevation: Oblaimd from system design plans on record-If cbecked,date of design plan reviewed: Nerved aite(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Cbeclmd with local excavators,installers-(attach documentation) Accessed USGS (-\e 3 d� = 2 •Z l Y must describe w you estab' the high gr ua waT kvation: f 1 c I V�0 is LZa, a �eJe1 Tol. C fnon.otinn Rnrm Ail cnnnn l i Town of Barnstable �pF tHE rp� ti* Regulatory Services Thomas F. Geiler, Director BARNSUBLE,MAM f p Public Health Division ptED�� - Thomas McKean,Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 This septic system inspection report was completed by a private inspector who is certified by the State of Massachusetts, Department of Environmental Protection. Although the Town of Barnstable Health Division received the original/copy of this report; this Division does not warranty the functionality of the septic system in the future nor does this Division agree with any technical observation s and interpretations contained within this report, In addition, by receiving this report the Town of Barnstable Health Division does not automatically approve the number of bedrooms listed within this report. The actual number of bedrooms approved at a particular property would-be listed on the"Disposal - Work Construction Permit". If you should have any questions regarding this report, please contact the certified Septic System Inspector who conducted the inspection. LOCATION '� E GE P M 0• ' t PILLAGE �i INSTALLER A i DDRESS ,�,SUILDER OR .0 NER DATE PERMIT ISSUED DATE COMPLIANCE ISSUED �pUSa _� b /a0a Npp,�P��µ�,�.} � J a U� J , r Fimic THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ........... ..............................OF.............................._........ k Appliration for Disposal Works Tonstrurtinn Prrmit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at Y '> j ..............C��! ?J .. GtCr.....1�L��15 .� �&g .J. .....------.....---------..........�a.�....y -------......................----- _ . ll Loa'on-Ad ress r Lot • -------. . ...1' r... t�l/ - 113 fA._� �_�L� r----4__�4:l?q2..`�.�..a ............ Owner Address ....................................... .......U .._. ?..5 ..: Instail, Address Type of Building Size Lot... 4�� .......Sq. feet V Dwelling—No. of Bedrooms-_-___I.................................Expansion Attic ( �) Garbage Grinder �a4 Other—Type T e of Building No. of persons............................ Showers YP g --------•---••-•---•---•--•- ---(---->--- Cafeteria ( ) dOther fixtures --------•---------------------•-----------•----------.--•-•••••-•••-------•-•-----•-••--•.........•••... •••••- W Design Flow................ 0........_._ ._gallons per person per day. Total daily flow...........3,1'._57� ......................gallons. WSeptic Tank—Liquid capacity j&, gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No.........�...... Width......� ----- Total Length.....____. Total leaching area..6`..............sq. ft. Seepage Pit No.........a ......... Diameter....... '__-_-__ Depth below inlet...G_�'�..... Total leaching area..../Qd.....sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results- Performed by.......................•._.................__......r_ ... Date.................. Test Pit No. I.....3.........minutes per inch Depth of Test Pit...I7,7,77_.j�__ Depth to ground water.__..d___.�Q1`otaa 44 Test Pit No. 2......5........minutes per inch Depth of Test Pit___ X.______. Depth to ground water........a v.- Description of Soil !!`�'P.-. s ''� -/-...... , :Me ..... --....... Z............... x 1°.-•-••Via-.=r r- 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 TITI..B 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has be ' ued by the oa of health.000 y Signed ••••...-_••••• -•• ..... of �`? ._..... Date ApplicationApproved BY.................................................................................................. Date Application Disapproved for-the following reasons:--•---------------------------------------------------------------------------------------------------------••-- ...........••••••••-•-••••...............•••-••••••••-••••••••--•••••--•---•---••---.........•--•••-••----•---•-••-........••---••------•••••--•-••-------•••••-••••-----•••---•----••-•-•••••....•-•--- Date PermitNo.... . ............................................. Issued_....................................................... Date No._.............--.....-- FEs............................ �1THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ................... .. ---..:...-:......OF...:....:-..... Applir ation for Diopos al Works Tontrudion rrut t' Application is hereby made for-a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal system %A&616 tic{, W arxsfyd ........... I•-•••----.......�................ .................................. ,p.t : .. ....a_ ..... ..................( �)tLoq'ilyrb�l d e I alo Zama -�1/�•��'S-�"i- f�il ,.r ..............�r _'t_,....___......--- _.....•-•••--- --..._ Owner ddress )Vol ......... -------- ------------------ Installe Address AW O U Type of Building Size Lo .....................Sq. f Dwelling—No. of Bedrooms.._.....3.................................Expansion Attic ( 1) Page Grinder 4 Other—T e of uildi of persons �_.: Showers YP _------------_- •-- P ( ) — Cafeteria ( ) d Other fIKures --------•-•-------------- ! ............................. g .. .. ...: ..............gallon per person per day. Tot ily W Des> n Flow-----••- --- -_*city - -- flow............................................gallons. WSeptic Tank—Liqu acltygo...gallons Length................ Widtl6._.__�!_... Diameter____.:.:•..__..Qepth_._..._......... x Disposal Trench—No._$!-'_---__----_-_--__ Width.................... Total Length.. _ ..... Total.leaching area...._y Sq. ft. i Seepage Pit No..................... Diameter.................... ,;Depth below inletf T_if::'._. Total leaching area..-.... _. oft. Z Other Distribution box ( ) D ing f nk ( ) �T a Percolation Test Resultsned , ,......, -'- ----- -- -----•-•,••,--- ........... Date----.....------------------- . 1y� -_----- � Test Pit No. 1................minutes per inch Depth of 'rest it _l___.__ 00 t l P P P g { ----•---- � Test Pit No. 2________________minutes per inch Depth of:Test Pit.:-...--..-:--:--.---Depth to roun ater.-'-. i...-._.___..... d • --•- Descriptionof Soil--------------•------..............--•---------------••-----.....:.-------•--------•----•------•----------.... - - U __-•----------------------•---------------••-Via.-------- ------------••-----•------------------------------- >-•----=.... x airs --•--.--------------•--------------------------------------•---•-----------•----------..._-----••.................................. Nature of Re or Alterations— U P Answer when applicable............................................................................................... ..............••.......-------------------------•---------------•--•-•----•---------------------------•------------• Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary C de—The 'nd i�gnnee►d further agrees not to place the system in operation until a Certificate of Compliance has b '� f�' p Signed_._..__ ...................... - - Date ApplicationApproved By.................................................................................................. Application Disapproved for the following reasons-........................------••----•---------.....-•-----•--••-------------------• = ---------------------------------------. ...J_Q:f__...................................................................................................................................... Date PermitNo....................................................... Issued....................................................... Date J Y� THE COMMONWEALTH OF MASSACHUSETTS T role,es_ BOARD '(RIP"'JHALT1=1 ..........................................OF........................................................... ........................ 4,.$C-,VA Tntifirate of TompliFanrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by------------------------------------------------ -------------------------•-----------•------........-•--•------•---•----.........---------.......----•--•-•---•-•---._..._ r Installer ,y at......------ - ....----('t r c' r� P M ._ ---r -C�''------&��'° w�.sT t c ._.... ___A. __ has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No......fl/_k.�y4.).............. dated--------- ................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WWLL F.IJNCTION SATISFACTORY. _ { DATE...----., ..�L .�`l ?:: f ._. Inspector-----M-•--•••-------- THE COMMONWEALTH OF MASSACHUSETTS BOARD 01�= HEALTH ............. !t1 :.............OF.......... ....... No....., r,1== d FEE........................ Disposal Works Tons#rw Lion ramit Permission is hereby granted.......... ........1°•! , .c'r Y-----------------------------------------•- o to Construct ( X) orxRepair ( ) an Individual Sewage Disposal System at No........1 v r-=•.•---•-.&7.............. ..24 �.- Street as shown on the application for•Disposal-Works Constri ion„Permit No-__ �'- �'�+ Dated ... t� . ................ ...... oard of Health...._..--_..............----..... DATE....=....-/'�• .......-.................. s.. . ,wl , FORM 1255 A. M. SULKIN, INC., BOSTON Massachusetts Water Resources Commission/Division of Water Resources WATER WELL COMPLETION REPORT WELL LOCATION Address City/Town t�Or*C + LiS'Tttlttk '' G.S.Quadrangle Map Grid Location Owner Phil 1 ii i'.l.:.Z"CrY'4 Address 10b F!arrincla PT. . .'X c t.tti,1:3 i4 11 n . WELL USE CONSOLIDATED WELL Domestic Q Public ❑ Industrial ❑ Type of Water-bearing Rock Other Water-bearing Zones METHOD DRILLED 1) From To Rotary(type) Cable ❑ 2) From To Other Au 3) From To 4) From To CASING Depth to Bedrock u Length Diameter Type UNCONSOLIDATED WELL STATIC WATER LEVEL Water-bearing Materials Feet below land surface 66 1 Sand: fine❑ medium❑ coarse 0 Date measured ` -'a'�- ' Gravel: fine❑ medium❑ coarse(] Screen: GRAVEL PACK WELL Sloth .1 rl length -2 t from rrn to �{rs Yes ❑ No Q - Split Screen(or 2nd screen) WATER QUALITY TESTS MADE Slott/ length from to Chemical El Biological ❑ Depth To Bedrock •�'-�� PUMP TEST Drawdown r1 feet after pumping days + hours at C GPM. How measured Recovery feet after hours. LOG of FORMATIONS COMMENTS: (On well or water) Materials From To 0 o' m DRILLER H m Firm Cf3D Address *_^r• * ` City Registration No. Aerator s rgnature -1`1ease print firmly 10M-8/81.164843 � Z � L 63-Jan-06 Town of Barnstable 1/5/2006 Page NO: Consumptive Tanks that are 10,13,15,17,19,or 20+years old which Require Testing Fire Cwner Name/Address Tank Tag Install Test Dist. Map/Parcel No No Date Age Date Zoe Loc �f �CO BUCKLER,CHARLES W& 228197 01 00926 3/18/198,\`1 1 1/4/1996 N B 100 RIDGEWOOD-ELLIOTT f' 181 ELLIOTT RD V/ CENTERVILLE M 02632 CO LONGSTRETH,WILLIAM 227140 1 0 1/1/198 26 P /19/2001 1v B 390 ELLIOTT RD CENTERVILLE M 02632 NCO MELLON,RACHEL L 07000900 OS 00233 6/17/1988 17 1 5/8/1997 N� B 1 8554 OAK SPRING RD UPP ER_VILLE V 20184 CO MILLER,JAMES 0 JR& 0780690pg 02 01270 1/1/198 24 1 2/5/1994 B MILLER,MARGARET P l 115 LOVELLS LANE MARSTONS MILLS M 02648 HY BARNSTABLE,TOWN OF( 293001 09 00756 9/26/198817 1 /31/1994 Y B 367 MAIN STREET HYANNIS M 02601 /HY BARNSTABLE,TOWN OF( 293001 07 00754 9/26/1988 17 1 /31/1994 Y B 367 MAIN STREET / HYANNIS M 02601 `SHY BARNSTABLE TOWN OF 293001 08 00755 9/26/1988 17 1 /31/1994 Y B 367 MAIN STREET HYANNIS M 02601 HY CHRISTYS REALTY LTD P 327264 08 01133 5/1/199 12 1 3/3/1998 N B C/O CHRISTYS OF CAPE C 105 PLEASANT ST / HYANNIS M 02601 HY HERTZ 31102200q 01 01135 6/l/198 19 2 /26/2001 Y B ATT:TAX DEPARTMENT 225 BRAE BOULEVARD PARK RIDGE NJ 07656 63-Jan-06 Town of Barnstable 1/5/2006 Page NO: 2 Consumptive Tanks that are 10,13,15,17,19,or 20+years old which Require Testing Fire Cwner Name/Address Tank Tag Install Test Zoc Loc Dist. Map/Parcel No No Date Age Date HY HYANNIS FIRE DISTRICT 309230 02 00000 8/l/198718 1 /18/1997 N B 95 HIGH SCHOOL ROAD HYANNIS M 02601 HY MARANE OIL CORP 311079 07 00000 4/24/199 10 1 /18/1995 Y B %GETTY PETROLEUM CO 125 JERICHO TPKE JERICHO N 11753 HY MARANE OIL CORP 311079 08 00000 4/24/1995 10 1 /18/1995 Y B %GETTY PETROLEUM CO 125 JERICHO TPKE JERICHO N 11753 `SHY MOTIVA ENTERPRISES LL 311017 03 00892 5/1/198 18 3 /12/1998 Y B 1100 LOUISIANA AVE HOUSTON T 77002 VIHY MOTIVA ENTERPRISES LL 311017 02 00891 1/1/1987 O 19 3 /12/1998 Y B 1100 LOUISIANA AVE HOUSTON T 77002 HY MOTIVA ENTERPRISES LL 273079 04 00140 11/1/1986 19 2 /23/1997 Y B C/O EQUIVA SERVICES LL PO BOX 4369 PROPERTY T HOUSTON T 77210 HY/ MOTIVA ENTERPRISES LL 273079 03 00139 11/1/198619 2 /23/1997 Y B C/O EQUIVA SERVICES LL PO BOX 4369 PROPERTY T / HOUSTON T 77210 HY MOTIVA ENTERPRISES LL 273079 02 00138 11/1/1986 19 2 /23/1997 Y B C/O EQUIVA SERVICES LL �PO BOX 4369 PROPERTY T HOUSTON T 77210 HY MOTIVA ENTERPRISES LL 273079 01 00137 11/1/1986 19 2 3/3/2004 Y B C/O EQUIVA SERVICES LL PO BOX 4369 PROPERTY T HOUSTON T 77210 d 63'Jon'06 Town of Barnstable 1/5/2006 Page No: 3 Consumptive Tanks that are 10,13,15,17,19,or 20+years old which Require Testing Fire Cwner Name/Address Ma /Parcel Tank Tag Install Age Test Zoc Loc Dist. p No No Date Date HY v MOTIVA ENTERPRISES LL 311017 01 00890 1/1/1987 19 3 /12/1998 Y B O 1100 LOUISIANA AVE HOUSTON T 77002 HY VI NEW ENGLAND TEL&TE 326025 03 00000 11/27/1991 14 1 /27/1994 N B PROPERTY TAX DEPT,31 S 1095 AVE OF THE AMERIC N11LER, 16 YORK N 10036 HY LEONARD M E 328151 07 01296 1/1/1990 1 6/9/1998 Y B %CHACE,RUTTENBERG& ONE PARK ROW SUITE 30 1 f PROVIDENCE RI 02903 H-JRUMPLER,LEONARD M E 328151 08 01297 1/l/199016 1 6/9/1998 Y B %CHACE,RUTTENBERG& ONE PARK ROW SUITE 30 i ,PROVIDENCE RI 02903 HY RUMPLER,LEONARD M E 328151 10 01295 1/l/199016 1 6/9/1998 Y B %CHACE,RUTTENBERG& ONE PARK ROW SUITE 30 j` PROVIDENCE RI 02903 HY TOMKINSON,CATHERINE 311060 01 01050 11/5/199015 1 /11/1991 Y B �45 KETTLEHOLE RD W BARNSTABLE M 02668 HY V W M ASSOCIATES LLC 269159 04 01107 5/1/1993 12 2 /27/1996 B 34 HARVARD ST HYANNIS M 02601 i,�` , y 1 x� � Ste, c .r+ ° � . ' � � N +~ s a • .�f 4 a `� -. ,` J �.YY ` ` t ,', {,♦ . f I r � 5/ � �'• ,r Y•iR 3 1� t • Y t R4` t .` r .. .i �� W� ri ak •� �.. +,. C`h•, ► y j, t ' fit, "r'' �L•_ ,. 71 � s ` ,rtY"s`\,y��r w I .,F R ,•, ,v' •t 'f' 15 , r 1 r�V� y .. �.c , i •,, V :,,r —f}� � .«. 4 ` stir L + n .� +� '! " Je.' s 1 J!L ? •Y'"�'VV�r �. t •tM1 •K a� r• .4. , � �4.. _ vp ;.+:t c 1 ''y '�•."rl `�,R l�y'i r ..• � c, .y� 5 r. � , •' t. .. � „ �T, t r i 5 rtti' ; K'y. ,� r t =•Kr,rj" J .' rY r ,�. 4 ,� q I f • 1 I•.' ' } 'F L t. f -. S 44' J' . .' � '" t i " ��,.t '4<t�AJ� ',j•. s �. � e � i,.:� trt-,h• '� K as ,.�-+r �•- .g y . �,i * M �y ` ;.` as y. ^• r •E w •' 1 < v . ♦. t :\£ . .i A.. w, ` Aril' 4 1984 t•�V ,I- r•ay ��. «.-;\ W ` , � I r y .,sir �•N• S i r+C M d. \� ie�3 a� i" t ��,��"�}.�� i,'+! .`' ' � ' -... t5,. .. A ti. �. �°.� t. - .• � t h,.,..fit a ,R�` �� !- _y ' *�r• r �♦}� f�. yJ �-t, t ,. x5{ 'C ,. ,.• � �, W '� Q •,t ' i .f �''�!F1w� t� C\r i E,i t,., , yd r..•r*�.+t �tS. any. ' P ;,L cN t .f 1+ � ,�• A�{. S T.�N i ;y. f F F • Yt ,,f a¢ T ri.r i, Mr Philip. H. Murdyl;:, �. ; :. s' ,: r r�s , ;+, ` 106 Barnaclet I�riv@ ,y ' Marstons.Mi11s,"t.'Ma. 0.264$ ., r y.. , __ � 'tt7W s gy,�� e r � �. i -. -• . • •1 .0 � 'of `" .$ � , 1` tfl!tir Dear` Mr } Mu Ydy a.;-' .. .. f f•g a � ..t '� s '. J'S rT - • 4�� You�are�grante4V a,�vaiiance to install,a septic. leach"ing pit on"`Lots 4-7 Rettletao a�xoad;`;West'•Ba�nstable,, 135..'�feet' from your re11, and' 145 •feetN ;:r "'' ' from an abutter's well, An 71ieu;of'the, iequi'red-150•-feet, .with theJ,01,10wing�,'" y ,;'pr. conditions ,: s S'i r. t. ,. i � Yf, s �• s. T t :5 ., a•R r + � r �.• _ .t } t41 .,L, ,,s... 'tif .:v - s.' ♦4 "` �• "^.; w.'r kS♦' - i }!' The designing engineer must' be present' on sitei and isuperviae:the construction 'of the septic�s.ystem`:8nd must`certifyt in writing to the'. Bgard 'that th�es syst¢rwns ,constructed in•strlct $cordance: R� •. 'r! r d I} x,14,' r s M . , • _� '. ` with, is;design a a . e yr \` s '•' .« rsr i+'i 4;i jj`r t' `. 1`s2�.t tiK y.,.7'�° •t.. v fS. i\•`n a� a �.-f f ,yk^ � k+' } 1 ♦ .. �...•r, r +c�.., •.� + n��. e. M"d.,, }'S•;.. � 4'.,". ,5. .;'". P.<�'4.,�a ' ��.� t, R� .e., 1 r` {2j: The wellimnst `bey installed and the'waterr tested.bacteiiologic4ily t and1themical.ly O' or toi the".' ssdance�of4 a build_pg,,permit The water°must meet all of the standards eetab1fihed'by the\Sa'fe -Drinking , 'Ac t o f 1974 f 16 .(3) 'A1I* othiirr'regulations contained, in Title 5,-,o€1.the. State Environ- , 4 dental &aerand `Town •of Barnstable Heslth ltegulaCions must:•be •com= 1" `• .+ -, s. , 4 ,'.,, .r,.r. a 0. 4 a d' plied with ,. P� 1, U � ' f`. , i. , �..� •'e'.'e r 9j. i "� 4r1••. r r -E � S ��'� > ^,'p.M >.f 1� This ,variance,ezpires 4May rl=, 1985 i r1 s rC arPrta £�+ n � i" ;r# �" g� , ` r1r r t4,� ro , e i,�i ♦ 5 ," f , {{ +.., VervLt '� ,..� ,1 r a •a �' x ,'r ' �� • r. t •.xr { fir.'T ..��' � �. ,'64��•� kn d��i � shy •� ". �� f �." � . flob t' L y Chi`1' -Chairman + t'..:.t, r «�}., `. n .+_{, { ��. .A� 1 .- ; f{`. *.. fir•'�we S". v `'L .• � 1 r �'ti Ann Jan augh 4 l K, x 'H Y. Ing , M t,D., :^BOARD' OF HEALTH r . �s�• t TOWN OF BARNSTABLE ' vim'_/mm " �� n ' , i \, •y • +.. y' L re L .;,Y" .aZ •`h •✓' • -� i. ,n �' r \ �, a {'' \ ,� l ` r '. +. H . 1y. •C a+•. (r'.:{, ` xJ:�4' J 4'(.r\ { ..Y I 1 4 '4• «C y. (.Ji a s.y.,a�-`�''.�`k�," P�.`, }r; r�� !. ` ```\' c a '.i • ,s. �:�-• � 'yY'' >*u•�;�`+�1�'3:3� ,.r.'�� 4 w � 4 � �1+... r•.tK..: a" ,�. ti �� t ..s�t .,n � Iv � �.>: .41�s -�e•,�a•`�-- 9� '�y^•ec�+fi� ��•. ?,* - r •aw._s .aa��" r a` ..+. � ^.�x _ ��' '3f rlS:'^,•�� .,S.P S•�t - :. � .:_r`�'.'�} NO. DATE j 2 .'Y FEE z I` oFSHElO TOWN OF BARNSTABLE y P OFFICE OF . i BAHHSTABL : BOARD OF HEALTH i639 c uOR \0� 367 MAIN STREET � k' HYANNIS, MASS. 02601 VARIANCE REQUEST FORM All variance requests must be submitted five (5) days prior to the scheduled Board of Health meeting. NAME OF APPLICANT Philip H. Murdy TELEPHAE NO. 428-9361 ADDRESS OF APPLICANT 106 Barnacle Drive, Marstons Mills, MA 02648 NAME OF OWNER OF PROPERTY Philip H. Murdy LOCATION OF REQUEST hot #47, Kettlehole _Road, West Barnstable VARIANCE FROM REGULATION (List regulation) 150 Ft separation between well and septie system VARIANCE REQUESTED (Specific request) 135 Ft separation from owner' s well and 145 Ft separation from abutter'`s well REASON FOR VARIANCE (May attach letter if more space needed) hot width and topography do not permit greater separation PLANS - Two copies of plan must be submitted clearly outlining variance requested. VARIANCE APPROVED NOT APPROVED REASON FOR DISAPPROVAL Ro Xi IQ'C il'6s,' dhai-rbaW Ann Jane Eshbaugh H. F. Inge, M. D. 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