HomeMy WebLinkAbout0010 LANCASTER WAY - Health 10 LANCASTER WAY, W.3Ar.NST.
A=110-004.011
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments MIS
1
10 Lancaster Way
Property Address ,
Ronald Tinneyti
Owner Owner's Name
information is
required for every West Barnstable ✓ Ma 02668 4-10-17 ;
page. City/Town" State Zip Code Date of Inspection I"d
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
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not Matthew Gilfoy
use the return Name of Inspector
key.
B&B Excavation
�y Company Name
374 Route 130
Company Address
Sandwich Ma 02563
City/Town State Zip Code
(508)477-0653 SI 13640
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 by the Local Approving Authority
>7 � =v
4-10-17
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•�Pagge 1 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 10 Lancaster Way
Property Address
Ronald Tinney
Owner Owner's Name
information is required for every West Barnstable Ma 02668 4-10-17
page. Citylrown 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:
System was in working order at time of inspection.
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
w Title 5 official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
H 10 Lancaster Way
Property Address
Ronald Tinney
Owner Owner's Name
information is required for every West Barnstable Ma 02668 4-10-17
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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°w 10 Lancaster Way
M
Property Address
Ronald Tinney
Owner Owner's Name
information is required for every West Barnstable Ma 02668 4-10-17
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
❑ E Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than 1/day flow
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
10 Lancaster Way
Property Address
Ronald Tinney
Owner Owner's Name
information is required for every West Barnstable Ma 02668 4-10-17
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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
10 Lancaster Way
Property Address
Ronald Tinney
Owner Owner's Name
information is required for every West Barnstable Ma 02668 4-10-17
page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no" as to each of the following:
Yes No
❑ ® Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
❑ ® Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
❑ N 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): 5 Number of bedrooms(Actual) _3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 550gpd
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
10 Lancaster Way
M
Property Address
Ronald Tinney
Owner Owner's Name
information is required for every West Barnstable Ma 02668 4-10-17
page. City/Town 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 See below
9 ( Y 9 (gP ))�
Detail:
"WELL WATER"
Sump pump? ❑ Yes ® No
Last date of occupancy: OCT'16
Date
Commercial/Industrial Flow Conditions:
Type of Establishment: NA
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:
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 10 Lancaster Way
Property Address
Ronald Tinney
Owner Owner's Name
information is
required for every West Barnstable Ma 02668 4-10-17
page. City/Town 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: Date of last pump unknown
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 8 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
10 Lancaster Way
Property Address
Ronald Tinney
Owner Owner's Name
information is required for every West Barnstable Ma 02668 4-10-17
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:
1995
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 2
feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: >150' from SAS to wellfeet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Septic Tank(locate on site plan):
1'
Depth below grade: feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: Years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1500gallon
Sludge depth: 7
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 10 Lancaster Way
Property Address
Ronald Tinney
Owner Owner's Name
information is required for every West Barnstable Ma 02668 4-10-17
page. City/Town 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 29
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 14"
How were dimensions determined? Measured
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 in working order at time of inspection with liquid level equal to outlet invert. Tank is in need
of pumping at this time and should be pumped every two years for maintenance.
Grease Trap (locate on site plan):
Depth below grade: NA
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
W Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 10 Lancaster Warr
Property Address
Ronald Tinney
Owner Owner's Name
information is required for every West Barnstable Ma 02668 4-10-17
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.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade: NA
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
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
10 Lancaster Way
Property Address
Ronald Tinney
Owner Owner's Name
information is required for every West Barnstable Ma 02668 4-10-17
page. City/Town 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
11
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.):
D-Box was in working order at time of inspection with no sign of previous back up.
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.):
NA
* 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:
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Forums
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 10 Lancaster Way
Property Address
Ronald Tinney
Owner Owner's Name
information is West Barnstable Ma 02668 4-10-17
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: (1) 6'x4'
❑ 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.):
Leaching was in working order at time of inspection. No evidence of past hydraulic failure, damp soils
or ponding were found when inspected.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration NA
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
W Title 5 official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
10 Lancaster Way
'M
Property Address
Ronald Tinney
Owner Owner's Name
information is required for every West Barnstable Ma 02668 4-10-17
page. City/Town 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: NA
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 10 Lancaster Way
Property Address
Ronald Tinney
Owner Owner's Name
information is required for every West Barnstable Ma 02668 4-10-17
page. Citylrown 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
well
A -3,41 y B o&
A2- 3T w 4r_,..
W `6" 83-90' "
A4.45'll" B4-74' R R
.............. .............. .
-�7 ION
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
W Title 5 official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 10 Lancaster Way
Property Address
Ronald Tinney
Owner Owner's Name
information is required for every West Barnstable Ma 02668 4-10-17
page. Cityfrown 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: No GW 144"
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: 3-18-1995
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:
Plan on file with BOH.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 ail
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 10 Lancaster Way
Property Address
Ronald Tinney
Owner Owner's Name
information is required for every West Barnstable Ma 02668 4-10-17
page. City/Town 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
AsBuilt Page 1 of 2
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PERMTTDATE: V—Z '9 COMPLIANCE DATE: 7-v
Separation Distance Between the:
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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 faci'ty) Feet
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Separation Distance Between the:
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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) Feet
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dOther fixtures ----------------•--------------•------------------------------------------------------ -----------------------•----------•-•----•-•----••-•---------
W Design Flow--------------5S-.......................gallons per person per day. Total daily flow_-_-____-___S __.___._.___..._......gallons.
WSeptic Tank—Liquid capacity. 5_P_galIons Length_JI----------- Width__-_�;-..-_____ Diameter-----_---------- Depth....
x Disposal Trench—No. .................... Width.................... Total Length-------------------- Total leaching area....................sq. ft.
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Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed b TJ+,0 A.5..__M.!�L U-UVIJ.................... Date-_-.3....I.'�
..a Test Pit No. 1 -------minutes per inch Depth of Test Pit__. -9.!f_"..... Depth to ground water_..AV/V&____---
44 Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water--._-___---_-___---____.
O Description of Soil...W
--• ---- --AT � .. -.S ................................
----•---------------------------
VNature of Repairs or Alterations—Answer when applicable...............................................................................................
..••--•---••--•---••---•••-----•--...--••-•--•---------•-------•---•-•---•-•--•-------•---------•••--...•--•••--...•-•------••---•--•--•-------•----•--•---•-----------------•--••-••--•------------•--•
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code —The undersigned further agrees not to place the
system in operation until a Certificate of Corn,
/61nce has dof health.
/ > (�
Signe ..
to ....� ....
Application Approved By .... .. ................... ... J...... - .. ......./ .....--- --�[e
Application Disapproved for the following i sons:
....................... . ---------------------- .........-..........---------...----------------......--------.... ---------------
® Date
Permit No. ' I Issued .7.- ................
Dare
�� __. __--__---_---_---_-----_--.—_.—.— _—__—-----_--_----.—._._.—.----.---_—
�5�,-�
�� ��� i
� � ° �
��
THE FOLLOWING
IS/ARE THE BEST
IMAGES FROM POOR
QUALITY ORIGINALS)
I M ^C&L
DATA
c� v
�' 's•''* 1 �� THE COMMONWEALTH OF MASSACHUSETTS - .•�
; ��� � v _,,-BOARD OF HEALTH � i ✓
yf j C TOWN OF BARNSTABLE
Appliratinn for Dhjip ial Works Cnnn,strurtiun Prrntit
Application is hereby made for a Permit to Construct (X) or Repair ( ) an Individual Sewage Disposal
:System at:
......��? .. �� ANc,asttin.....
�y......U':..'� 2ti ct _; `
Location.Address � r or L,qt No
iA
owner ^� ' Address
iT:?.... �_:�T•(�t,tc-i� 1 �71�t���c�.�_��.��n.�e�_�W,i?.G7Z�o.�S �{t���•:t!l 11�
Installer 1 Address
Type of Building Size Lot... �,.37_ ......Sq. feet
t-t / Dwelling—No. of Bedrooms------------ -------------------------------Expansion Attic ( ) Garbage Grinder ( )
PL4 Other—Type of Building ---------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( )
Q' Other fixtures ------------------------------- - -
w Design Flow.............5 ........_---------------gallons per person per day. Total daily flow_..---------- ..........................gallons.
_
WSeptic Tank—Liquid capacity-15_P.gallons Length-JI........... Width---- --------- Diameter---------------- Depth.... ..'.E:!'.�
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No-------TIm�a-..._.. Diameter------!.77------ '__ Depth below inlet_._!-:............ Total leaching area.aa!.GJn_sq-.ft:
Z Other Distribution box ( ) Dosing tank (, )
~' Percolation Test Results Performed b (�l9MfK!?-5....M.L-k--:`_Q�--------_•_--•__-.-. Date._...=_�.: _..
�7 Y k,. f
Test Pit No. I...`-.z -__-minutes per inch Depth of Test Pit....L-` ..Ll........ Depth to ground water.._�Qlli.f
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
W _.------ .... :...
D Description of Soil Z`� - To. -$u Sd!.-1.......Z .�..`r� „ t� T-tA..S/A
x L o - 1 y` "---c-L:t.o-"......m�b�v.,•,----�►N+_-S,aN .........................................._.....----------------------•c,
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 Complance has been issued by the board of health.
� > .
� f Date
Application Approved By ...__. /.-.1:......'.. J ---. ?j :............... �' I`
Application Disapproved for the following �'easonf- ------------------------------------------------------------------------------------------------ -------------------------------
Date
-----------
Permit No. ------- - Issued ...........................��............
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Ter#tfiutt#e of Compliance
cce
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( (/) or Repaired ( )
b hst.utt
----- - --------- -- ----- -- -------- - ---- -----
� .:...:... l - ' ....
.�
at ..��! �� -------
has been installed in accordance with the provisions of TITLE of The State Environmental Code as described in
the application for Disposal Works Construction Permit No. 7.a� /®. ,�' dated `���.//... ... .."........
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION FUNCTIONSATISFACTORY. �
DATE /... ..........1. ....f...%'-.. - --------------------- Inspectors.._.,.-- ��'�% ... ='--
- - -
------------------------ -----_---------------------------- --- --------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
ems' TOWN OF.BARNSTABLE /G U
No... FEE-:5.-�U-�_ -•---•--..........
�t��n��tl nrk� ��rn�trnrtilan �rrntit
' _ > _7 ,
Permissionis hereby granted---------- --- --------- ----------='-•---------------------------:.----•--------------'---•----•----------•--•-------•-••-----
to Construct ( 1,)or Repair ( ) an Individual Sewage Disposal System
Street
as shown on the application for Disposal Works Construction P it No._-9s=�U3-- ated_y.. �./�5.".......
Board of Halth
DATE-----•---v/ --- .. ..
FORM 36508 HOBBS&WARREN.INC..PUBLISHERS
a
No. v Fee------- ------------
� BOARD OF HEALTH
c
TOWN OF BARNSTABLE
Applicat ion-*r Melt CootructionA9ermit
Applicat' n is hereby made for a,�rmit to Construct (X, Alter ( ), or Repair ( )an individual Well at:
/ ----- i� ' � _ -�-� - -- - ----- ----------------_—- —---__
Location Address A sots Map and Parcel
// 1-- Address
-------------------- � fi ----- -�
Installer — Driller Address
Type of Building �gaze
_,/- <�
Dwelling ----- - - - ---------
Other - Type of Building----------------------------------- No. of Persons----------------------------------------------
Type of Well- —
Purpose of Well---- -�1 <<-- -------------
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 unti a Certificate pli ice has been issued by the Board of Health.
Sign -— -- ----a-------
O _ ate
Application Approved By — --- ---- --- _
date
Application Disapproved for the following reaso :--------------------------- --------------
--------------------------__________
/date
Permit No. - -- —-------------- Issued--- -- - q-� -
...1— --------------
—` date
r— — — -- BOARD OF OF HEALTH
TOWN OF BARNSTABLE
(Certificate ®f (Compliance
THIS IS TO C IFY,,That the Individual el onstructed ( ), Altered ( ), or Repaired ( )
by--------------- � �- --- ---------------- - - -- ------—--
(�I fIn Iler
at------------- --�� l- � �0 K
- ---tVX74W-0---------------------------
has been installed in accordance with the provisions of the Town of Ba 'le Boa/r�of He_ ivate Well Protection
Regulation as described in the application for Well Construction Permit No.E,/(,�- - ated----------------------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL
SYSTEM WILL FUNCTION SATISFACTORY.
DATE---- ---— -- --- — -- Inspector-- - ------------------------------- -----------
��,3,,.. ,�,�',r.,•�d;,1.. . .Y^».�»�.��y„�y..�*^`Y-►sxe�4'�:z+�,s.�wr"r''�"f%'t4r'"' �?"�-fi'xiRr..Xc'�-y..^�,:a;�i`"�''+C"�""'••**`"'``^�T.r'sY'-'�'"�""Yj�C•r.'rr�j"`.�'� "y i,i���e.rr'�,_'"•..`!'"
----
No. � Fee------a_
BOARD OF HEALTH
4 TOWN OF BARNSTABLE
'y e
Application for lVell Con0ructionPermit
Ap• icat' n is herebymade fora ermit to Construct (�(}, Alter ( ), or Repair ( )an individual Well at:
- - -�----
Location — Address As sors Map and Parcel
O er Address
------------- ------------------------------- 3 -------
Installer — Driller Address
Type of Building
Dwelling ---------
Other - Type of Building ------- No. of Persons--------------_________—__—_—_______
Type of Well � -
— -—y— - Capacity-------------_--------— -—— — --— —
Purpose of Well----f�G - -�'�-s----- ----- —-
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 a Certificate mpii nce has been issued by the Board of Health. r/
ate ——
Application Approved By - — --- ----- - k ---
------- -------------
date
Application Disapproved for the following reaso :-------------------------------__—___
------------------- — — — --------------------------------------- ----- -------
0
date
Permit No. JA -------
--- Issued -------
-- ----- - ----
date
_ _B0ARD•.O.F_H,EALTH
TOWN OF BARNSTABLE •
Certificate Of (compliance
f
THIS IS TO C R IFY, hatete Individual el'= onstructed ( ) Altered ( ), or Repairedby- --- � — �— Q -- ------------—-----------—----------------- . -- --------
jn ller --- ------
at- -- -- —c.. � C� - ��y� g-------------_----------
has been installed in accordance withAhe provisions of the Town of Ba stale Boar of Healt vate Well Protection
Regulation as described in the application for Well Construction Permit No. ,- - ated------------------------
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
.� We'll Con5truct ion Permit
No. -- - - ------ m Fee--;; --------
Permission is hereby granted-- - �1-` ----------------------__-------__
to Constr ct ( ), Alter qr Repair ) an I i al MAY-t--ah?
NO. ---- J— � — ---------------------
street
as shown on t e pplication for Well Construction Permit
64
No. ----------- -- - Date
_- -___ ;rt
----
Board ealth -r
DATE---- - - --
c �
ASSESSORS MAP.• ff0
PARCEL; 4-11
ea
CURRENT ZONING: RF
�$ BUILDING SETBACKS:
R.
FLOOD ZONE: —C
Lg'C. YA1118oLB
4 `.
\ UTILITY CLUMB
c
'CATION NAP \ -94
(LUT�BD ABLL a1�G�
LOT 10 84 ' - '
98
0.7`0 ±AC.) O � ` g O ' '
.90
O
'ex,
,e
15d -
98.. O
�OPQSBD 177BLL '� ,
y •
b6.0� • ' .3 , • - .
79
1�1 \ 84 � '
Y
/ / /
10,
le
le le
� i
or
lip
o to
ol
10,
88
LP- ARM
7pQ D — � ' r8-5
l t'IS?7AIG L ACH PIT
5. 8 1 1 1 I 1
t 1 1 1 84
� Nd
B
rN BLRV.75Z �� 1
`— 1 B.
78. 5 � . � ` '70
•78
G '74
78 8. s
NTOUR: _
oxTnTrp. .... AcHINO
MAR-31-95 FR I .16 :45 EN,V I ROTEfvH LABS 508 888 6446 P. 08
Y ENVIROTECH LABORATORIES,ORIES, INC._
MA Cert.No.: M-MA 063
449 Rto. 130 • Sandwich,MA 02563
(508)888-6460 • 1.800.339-6460
FAX(508)888-6446
CLIENT: Reef Realty LOCATION: Lot 10 -'
P.O. Box 186 Lancaster Way
W. Dennis, MA 02670 W. Barnstable, MA
SAMPLE DATE: 3-28-95
COLLECTED BY: Clifford Well Drilling DATE RECEIVED: 3-28-95
TIME: 4:OOPM LAB I.D. NO. : E3-418
JOB TYPE: New well SAMPLE I.D.NO. 10
WELL SPECS. : 92'
RESULTS OF ANALYSIS:
Parameters Units Recommended Limit Result
Coliform bacteria/100ml (MF Method) 0 0
pH pH units 6.0-8.5 6.18
Conductance umhos/cm 500 75
Sodium mg/L 28.0 7.9
Nitrace-N mg/L 10.0 0.12
Iron mg/L 0.3 0.12
Manganese mg/L 0.05 0.010
Volatile Organics See enclosed report.
EPA 601/602 ug/L None detected.
Yes No WATER IS SUITABLE FOR DRINKI URPOSES OR PARAMETERS TES;D.
xxx � ! .ice Date
R naJd J. sari
Laborato y Director
LT = Less Than
IL
MAR-31-95 FRI 16 ' 5 ELLYLEOZECH LABS 508 888 6446 P. 09
°- ?M t p.oUNPWA'TSR ANALY'1ICAL
ENYIROTECH 508 759 447619 2/ 7
j -
ANALyTICAL EPA 14ETRODS 601 and 602
Volatile Organics (6C/PID/ELCO)
, Lab D: 10297-01
Field ID: E3418
BatchID: VG2-0584-V
Protect: Reef/Lancaster Sampled: 03-28-95
t: Envirotech ived: 03-29-95
Clien ece
l Cool
R
Cont/Prsv: 40mL VOA Yial/NC Analyzed: 03-30-95
Matrix: Aqueous
PARAMETER CONCENTRATI(ugON REPORTINGtLIg I
BRL 5
Dichlorodifluoromethane BRL 5
Chloromethane BRL 5
Vinyl Chloride BRL 5
Bromomethane BRL 5
Chloroethane BRL 1
Trichlorofluoromet'hane 1
1,1-Dichloroethene BRL I
Methylene Chloride BRL 1
trans-1,2-Dichloroethene BRL 1
1,1-Dichloroethane 1
cis-1,2-Dichloroethene BRL 1
Chloroform BRL 1
1,1,1-Trichloroethane BRL 1
Carbon Tetrachloride BRL 1
Benzene 1
1,2-Dichloroethane BRL
BRL 1
Trichloroethane BRL 1
1,2-Dichl-oropropane BRL 1
Bromodichloromethane 5
2-ChloroethyyI Vinyl Ether BRL 1
cis-1,3-Dichloropropene B L 1
Toluene 1
trans-1,3-Dichloropropene BRL 1
. 1,1,2-Trichloroethane BRL 1
Tetrachloroethene BRL 1
Dibromochloromethane 1
Chlorobenzene BRL 1
Ethylbenzene 1
meta-and par&-Xylene * BRL 1
ortho-Xylene * BRL 1
Bromoform 1
1,1,2,2-Tetrachloroethane BRL 1
1,3-Dichlorobenzene ERL1
1,4-Dichlorobenzene 1
1,2-Dichlorobenzene BRL
QC-SURROGATE COMPOUND SPIKED MEASURED RECOVERY QC LIMITS
a,a,a-Trifluorotoluene 30 30 100 % 87 - 113 %
1,2-Dichloroethane-d4 30 30 101 % 83 - 117 Y
8RL = Below Reporting Limit. • Non-target compound. kethcd Raferanees! Method 601 - .pvvaable
Halocarbons and Method $02 - Purgaable Aromatic@, 40 C.F.R. 136, Appendix A (1986).
ASSE
SSORS MAP-- '-110
�-�► .
. T.� ►� T HOLE LOGS
NOTES.
. PARCEL: 4-11
ASSUMED FROMQUADNGVD`# -
a 1.`VERTICAL DATUM: ( �L
5. ZONING:'° ENGINEER: 0 McLELLAN P.E.
. RF EN TH MAS , 2. MUNICAPAL WATER IS NOT AVAILABLE. G
. CURRENT .
WITNESS: G JERRY DUNNIN D THROUGHOUT SEPTIC SYSTEM.
• BUILDING SETBACKS. 3:SCHEDULE 40 4 PVC PIPE TO BE USE
t DATE. 3 93
c 9 . ALL PRECAST UNITS TO CONFORM! WITH AASHTD H f0 & H 20
�► F. S. i5 R. 15' 4
R�►
4TION RATE. < 2 MIN IN-
� PERCOL / SPECIFICATIONS.
,
. : LOADING F _
_ SOT RWISE .
2 5. PIPE PITCH f 4 PER FOOT, UNLESS NOTED HE
Lows
- FLOOD.ZONE. TH f TIi �_ (UNLESS_ �
MANHOLE
'ELEC.
w:.76A D.LEPEL,
6. FIRST 2' OF PIPE OUT.<OF D-..BOX TO BE LAI
' TOP �r
ELan.
CC MODATE THE
i1TILITY CLUSTER , ' 7. THE SEPTIC .SYSTEM HAS NOT BEEN DESIGNED TO A 0
SUBSOIL
24" 74.0
O ,
0 GARBAGE .DISPOSAL.
-1
USE F A
A SILTY
W E .;
CONFORMANCE WITH TH
FIN1: a
8. ALL: CONSTRUCTION DETAILS ARE TO BE IN �
G
94 ,
SAND STATE.OF MASS. ENVIRONMENTAL CODE (TITLE FIVE) AND LOC
AL
LOCATION MAP
i
1 SALT REGULATIONS.''
PROPOSED WELL` G �,_ HEALTH 1Z
94
(LOT B
1 tv 9z
) UTILITIES PRIOR
'� 9. CONTRACTOR TO VERIFY LOCATIONS OF ALL
C : � MEDIUM
LOT 10
� o
o FIh
_ TO CONSTRUCTION.=
0 , o ,�
s0 5 + S.F. �90 SAND
_ S
O
0.70 + AC. S
_ � L�' � 10. DESIGN ENGINEER TO INSPECT AND CERTIFY SUITABLE SOIL-CONDITION
T ME F CONSTRUCTION.
9,2. 6 �88 144" 64A
TO A DEPTH OF 4 BELOW LEACH PIT A TIME 0 ;
/
1� ENSURE �`LEVE NESS AND E
_ 11. D BOX TO BE WATER TESTED.TD UAL
L Q
sz
. . 5
•
FROM
AND WELL LOCATIONS HAVE BEEN MODIFIED F
86 12. SEPTIC SYSTEM _
MASTER PLAN REVISED 5 2 93 ON FILE WITH BARNSTABLE HE
ALTH
'� 11. 5 , NO GROUNDWATER ENCOUNTERED )
PROPOSED WELL ! -DEPT. ALL PREVIOUSLY APPROVED 'SETBACKS REQUIREMENTS REMAIN
� � � , 82 (CROUh/DpATER ON LOT 5 AT ELEV. 48.f)
(LOT 7) ,
o . , IN:EFFECT.
90 . ,
�" ,80
0 s ,
0
ell _ i , I
i , ,
88 _ 76 SEPTIC SYSTEM DESIGN
p.0
OAS , 74
/ ` 7 i' 12
%, �
5.
FLOWESTIMAT E.
68 bEDR00MSA T 110 50GAL DAY
WALK-OUT
G 9
i
I
ss
1 J
Q 84 r SEPTIC TANK.
,.- , ,
r * _
25� � � 550 GAL DAY 1.5 DAYS. 8 GAL ,
G _ ,
o � e . _ TANK• USF ' GALLON SEPTIC"TA 'PRopos
f5D0 :
24' >5 BEDR . E
y1' 8,Z ;
DUELLI
, , ♦ 8'
LEACh ING AREA
GARAGE
r' :. •. , is - 64 :
� r , 4 WITH 3''OF STONE 2
ITSI 2 LEACH PITS (6' x )
36'
cD _
,
i
s / g
,
,
x 4 DEEP ..
!� _ 12 EFFECTIVE DIAMETER
l AC PROPOSED DWELLING
Irj �
� . Y o _
cl T SIhE.:AREA. - 2.5 377 GAL DAY
1� I,L 12 x 4 x PI 151 SF � � �
81s / (� GAL' DAY
00 / BOTOMAREA. Sx6xPI = 113SF (1.0) 113
4 . i GAL DAY
0 p 0b �'OTAL CAPACITY /
x 2 PITS = 980 GAL DAY
r
i
--�-_ sz 2» PEASTONE
� 0 , SEF;T I C SYSTEM ;SECT ION
o ;
OF3 4" - 1. 1 2"
r
Ras � WASHED STONE -
_85.0 COVERS WITHIN 12"
� r
o
/ r
i OF FINISHED GRADE
TOP OF FOUNDATION.
TH-5
-------------
1
r
1
. r
e �
� 76� � 1
62
D .. 6
DRAINAGE EASE ENT 75.43
LEACH PIT
� EXISTING LE 4
1 1
ELEV.
� D BOX _ • "
5.68 LP-I: 64.0
1500 GAL ELEV.•� s4 LP-2: 60.0
,�• 75. s � - ELEV. 75.37
SEPTIC TANK
ss _ f----. �-�sELEV.
y � � ELEV`68 .
LP 1. 68.0 ,
,�• .
39
3
CE TE
BENCHMARK N � SIZES._' t TEE I
- ♦�
IN ELav�rSz 7s 76.0 ELEV. 12' `
CATCH BASIN .. 7D 1
ELEV. INLET. 6" UP 10 DOWN
7s. s .. : _4 WITH
72 TWO LEACH PETS 6 -x
OUTLET. 6" UP, 1 DOWN , ,
UNDER 3- OF STONE 12 EFF.`DIAM. x 4 DEEP H-20
D
l BASEMENT : 64.5 - 62 58 x 150 - 7'
) BREAKOUT CALC. ( )/
78
• S 8 ;
SITE AND SEW
AGE PLAN..
APPROVED BY. DATE.
APPR '
KEY. I N
K 0CA TION.
d �
A 771
CONTOUR: E �✓
EXISTING ON L
T
.•. ............ . ,
L '
PROPOSED CONTOUR: E � ��+���� LOT 10 LANCAST ER`WAY
w r, .<,
C SPOT ELEVATION: 5.5
EXISTING 2 _ 0' 1
5 � . i•,za0� y ,,� raJ �
1 \\
c i r ,
MA
�,. _ WEST BARNSTABLE
SPOT ELEVATION. 25 r+�._c .
PROPOSED PO � wn�
z . !w r _
f
vv u
`R
4
C+ ... ti
HOLE:
t'� Sa. :.
TEST H �,: .._.. -,,
f
. . � D OR._ .. � PREPARE F
UTILITY POLE. -0- c
v
FENCE LINE �S. ,L� 1 -
w �� ,<-� REEF REALTY
T.
t
RAN •
HYDRANT: ( ' _ _
,� 1" 30' _
G WALL.
DEYAREST-YcLaLLAN ENGINEERING 'YY^
SCALE. DATE 3 18 95
RETAINING
STREET P.O.BOX 4ss
24 SCHOOL T `: ' . 96
PLAN BOOK 454 PAGE
14EFERENCE.
SS CHUSA'TTS 02670
WEST DENNIS, YA A
J . PIS
JOHN Z. DEMAREST R
DM 1 3� -028 -
THOMAS �{lcLELLAN,`P.E ,