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0012 LISA LANE - Health
12 Lisa Lane West Barnstable / A= 111 —023 CERTIFICATE OF ANALYSIS M' Barnstable County Health Laboratory (M-MA009) z Recipient: • Sally Desmond Matrix: Water-Drinking Water ` - Desmond Well Drilling ' Sampled: 03/08/2016 13:00 ^ " P 0 Box 27.83 Received: 03/08/2016 13:55 Collection Address: 12 Lisa Ln.W. Barnstable, MA Orleans, MA 02653 Sample Location: Depth 80760' gt4er#: G1692030 Description: lday-12 Lisa Ln Last+ID: 1692030-01 Date Analyzed: 3/8/2016 @ 10:48 Sample#: Analyst: yn Method: EPA 524.2. Dilution Factor: 1 Comment: Water sample meets the recommended limits for drinking water of all the above tested parameters. _........ ....._-........____-..... --..._ ...... ........ EPA 524.2 - Volatile Organics by GC/MS Rug'' sult MCL NjgDL parametResult MCL MDL er /L ug/L y ug/L Parameter ug/L ug/L ug/L Dichlorodifluoromethane ND 0.50 Chloroform 0.88 80 o.so - ..... Chioromethane ND 0,50 cis-1,2-Dlchloroethene ND 70 0.50 - ...--- - qn Vinyl chloride ND 2.0 0.50 cisis=l,3 Dichloropropene ND 0 Bromomethane ND 0.50 Dibromochloromethane ND 0.50 1,1,1,2-Tetrachloroethane ND 0.50 Dibromomethane ND 0.50 Il,i,l-Trichloroethane ND 200 0.50. Ethylbenzene ND 700 0.50 _ - 1,1,2,2-Tetrachloroethane ND 0.50 Hexachlorobutadiene ND 0.50 1,1,2-Trichioroethane ND 5.0 0.50 Isopropylbenzene ND 0.50 1,1-Dichloroethane ND 0.50 Methylene chloride ND 5.0 0.50 1,1-Dichloroethene ND 7.0 0.50 Methyl-tert-butyl ether ND o,50 ,1,1-Dichloropropene ND o.50 Naphthalene ND o.50 �._. ._.. 0.50 n-Bu (benzene ND 0.50 i1,2,3-Tr3-Trichlorobenzene ND ty 1,2,3-Tnchioropropane _ ND o.so n-Propylbenzene ND 0.50 1,2,4-Trichlorobenzene ND 70 0.50 p-Isopropyltoluene ND 0.50 � 0.50 sec-Bu (benzene ND 0.50 1,2i 4-Trimethylbenz_ene ND _ ty - ND 100 0.50 1,2-Dibromo-3-chloropropane ND Styrene 1,2-Dibromoethane(EDB) ND 0.50 tert-Butylbenzene ND 0.50 12-Dichlorobenzene ND 600 0.50 Tetrachloroethene ND 5,0 0.50 �� - 5.0 0,50 Toluene ND 1000 0.50 1,2-Dichloroethane ND 1,2 Dichloropropane ND 0.50 Total xylenes ND 10000 0.50 1 11,3,5-Trimethylbenzene ND 0.50 trans-l,2-Dlchloroethene ND 100 0.50 _a 0.50 trans-1 3-Dichloro ro ene ND 0.50 1,3-Dichlorobenzene __ ND ----- --._p P.._. _...... _.�. - "-- - - 0.50 Trichloroethene ND 5.0 0.50 11,3-Dichloropropane ._ ND i 1 4 Dichlorobenzene ND 5.0 0.50 Trichlorofluoromethane - - ND - 0.50 _ ..'._ 2,2-Dichloropropane _ - - -ND -0.50 Surrogates %Recovered QC Limits(%) i2-Chlorotoluene _ ND 0.50 _ mo_Brofluorobenze_ne 112% 70 130 4-Chlorotoluene ND p 0.50 1,2-Dichlorobenzene-d4 106% 70 130 Benzene ND Bromobenzene ND 0.50 Bromochloromethane ND 0.50 Bromodichloromethane ND 0.50 Bromoform ND 0.50 _...._-...... -... -- -.......-......-........... ...-_.........-_... - Carbon tetrachloride ND 5.0 0.50 Chlorobenzene ND 100 0.50 Chloroethane ND 0.50 .. .._. Attached please find the laboratory cert Approved By: ified parameter list. (Lab Director) p l ND=None Detected RL = Reporting Limit MCL=Maximum Contaminant Level 3195 Main Street, PO. Box 427, Barnstable, MA 02630 Ph: 508-375-6605 Page 1 of 1 izSwpF !,i1kv�:, CERTIFICATE OF ANALYSIS Page: 1 of 1 Barnstable County Health Laboratory (M-MA009) Report Prepared For: Report Dated: 3/9l2016 Sally Desmond Desmond Well Drilling � P O Box 2783 Orleans, MA 02653 ►•: .......----._..... - -- ._-------— ...._..._..- Laboratory ID#: 1692030-01 Description: (Water- Drinking Water Sample#: Sample Location: _12 Lisa Ln.W. Barnstable, MA; Collected: 03/00SO16 Collected by: DWD Depth 80'/60' Received: 03/t 8t2016 Routine_M I ITEM RESULT UNITS RL MCL METHOD# ANALYST TESTED NOTE I Nitrate as Nitrogen 1.6 ' mg/L 0.10 10 EPA 300.0 LAP 3/9/2016 j i Iron 0.17 mg/L 0.10 0.3 SM 31116 LAP 3/9/2016 Manganese ND mg/L 0.025 0.050 SM 3111B LAP 3/9/2016 pH 6.4 PH AT 25C NA 6.5-8.5 SM 4500-H-13 DCB 3/8/2016 Sodium 16 mg/L 2.5 20 SM 3111E LAP 3/9/2016 Total Coliform Absent P/A 0 0 sin 9223 RG 3/8/2016 Conductance 150 umohs/cm 2.0 SM 2510E DCB 3/8/2016 Water sample meets the recommended limits for drinking water of all the above tested parameters. -j // /J a Attached please find the laboratory certified parameter list. Approved By: (Lab Director) \ C�� /?� f r/U( `/ G L' { ND=None Detected RL = Reporting Limit MCL=Maximum Contaminant Level 3195 Main Street, PO. Box 427, Barnstable, MA 02630 Ph: 508.375-6605 Massachusetts Department of Environmental Protection Bureau of Resource Protection t Well Completion Reports Well Driller Please specify work performed: Address at well location: New Well Street Number: Street Name: . 12 LISA LN Please specify well type: Building Lot#: Assessor's Map#: Domestic Assessor's Lot#: ZIP Code: Number Of Wells: 023 02668 Cityfrown: Well Location BARNSTABLE In public right-of-way: GPS : Yes jn tJo North: West: jil41.72202 70.39877 Subdivision/Pro perty/Descri ption: Mailing Address: Cl click here if same as well location address Property Owner: Street Number: Street Name: 0 HARA 89 BIRDS HILL AVENUE City/Town: State: Engineering Firm: NEEDHAM MASSACHUSETTS ZIP Code: 02492 Board of health permit obtained: jn Yes jn Not Required Permit Number: Date Issued: W2016 001 102/25/2016 Massachusetts Department of Environmental Protection Li Bureau of Resource Protection—Well Driller Program KWell Completion Reports(General) € Well Driller - General Well Form DRILLING METHOD Overburden Bedrock .......... Auger Choose Bedrock-- ....................................................................�........ ....._.... ..............._....._........._........................................ WELL LOG OVERBURDEN LITHOLOGY From(ft) To(ft) Code Color Comment Drop In drill Extra fast or Loss or addition stem slow drill rate fluid S ,Sand And Gravel �F Brown 6�:1 - ,� YES `,i NO ,j Fast n Slow ,� Loss ,1 Addi �..........__..._._._..:� .... ._ k._.......__.................._...._...................._ J J 10 30 Fine To Coarse S 6{ Brown 6 ' jai YES jn NO in Fast j,i Slow jn Loss jn Addi r30 _ 50 Fine To Coarse S ( � Brown g ',' ri YES n NO n Fast n Slow n Loss ,� Addi l- � .__ _ ._._........ � �� .I 1 J i n ,ri Fast �1 SlowK 70 i Loss jrt Atldi„ 3�. ............................................................... 70 75 Fine VTo Coarse S Brown i �� YES j jn Fast j,l Slow jn Loss jo Addi 75 80 TFine Sand Brown 6 fi n YES ,� NO I ,i Fast jii Slow jii Loss fii Addi WELL LOG BEDROCK LITHOLOGY Visible Extra Drop in drill Extra fast or Loss or addition of From(tt) To(tt) Code Comment Rust Large stem slow drill rate fluid Staining Chips Choose Code �' h, JrI YES jn NO J i Fast 1,7 Slow jn Loss Ir Addition k Ye Ye ._ � � G _.. ADDITIONAL WELL INFORMATION Developed jn Yes j,i No Disinfected Total Well Depth 80 Depth to Bedrock Fracture ............................................................................................. Surface Seal Type None Enhancement jn Yes j,� No CASING ti Is Casing above ground From: 1 To: 0 From To Type Thickness Diameter Driveshoe Lo 77 Polyvinyl Chloride g:€ Schedule 40 6 4 _ 6 Ye ................................................ SCREEN d No Scree Massachusetts Department of Environmental Protection Bureau of Resource Protection—Well Driller Program Well Completion Reports(General) a„ From To Type Slot Size Diameter 7780 Stainless SteelVWell Point ' y;p z, WATER-BEARING ZONES (� DRY WEL From To Yield(gpm) 60 80 10 PERMANENT PUMP(IF AVAILABLE) 2 Wire Constant Speed Pump Description Horsepower Submersible Pump Intake Depth(ft) 75 Nominal Pump Capacity(gpm) 10 ANNULAR SEAL/FILTER PACK Water Batches Method Of From To Material Weight Material Weight (gal) ("count) . Placement Choose Material 6 J L....._ _ .. ,Choose One WELL TEST DATA Date Method Yield(gpm) Time Pumped Pumping Level(ft Time To Recover Recovery(ft }} ((H"H:MM) BGS) (HH:MM) BGS) 03/25/2016....� Constant Rate Pump....._..6 . 10..........._... _1 1........30..............._�.... 65..........._......._...........1 �............................1 60_._....._.....................1 WATER LEVEL r Date Static Depth BGS(ft) Flowing Rate(gpm) Measured �03/25/2016 F60 --- COMME NTS Massachusetts Department of Environmental Protection Bureau of Resource Protection—Well Driller Program rr Well Completion Reports(General) W O} WELL DRILLERS STATEMENT h+ This well was drilled or altered under my direct supervision, according to the applicable rules and regulations,and this repbzis complete and accurate to the best of my knowledge. M PATRICK Monitoring[M] Supervising Driller DESMON Driller DESMOND Registration# 877 Signature PATRICK, DESMOND WELL Firm DRILLING INC. Rig Permit# 0551 Date Job Complete 03/09/2016 NOTE:Well Completion Reports must be filed by the registered well driller within 30 days of well completion. No. ® 6) 6 Fee BOARD OF HEALTH TOWN OF BARNSTABLE 0(pprication jar Veil Cougtructiou Permit Application is hereby made for a permit to Construct(41 , Alter( ), or Repair( ) an individual well at: A2- uso, Law, 1\11 07-3 Location-Address Assessors Map and Parcel Ul Aoxo, t0\ Owner Address Smrn�& Wd` bri\V��,\Vy- ? ()• 1`30i- L-Mj 06L1ans PA o2-(653 Installer-Driller Address Type of Building Dwelling J Other-Type of Building No. of Persons Type of Well hVe U1 '-1 S�MQ PJ L Capacity f O Purpose of Well?Oyc.9-� Agreement: The undersigned agrees to install the afore described 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 Certi c to of Co pliance has been issued by the Board of Health. Sig FS LI Date Application Approved t:) Date Application Disapproved for the following reasons: Date Permit No. �� /[A Issued ��b Date BOARD OF HEALTH TOWN OF BARNSTABLE Certificate of Compliance THIS IS TO CERTIFY,that the individual well Constructed( ), Altered( ), or Repaired( ) by Installer at has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation as described in the application for Well Construction Permit No. Dated THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORILY. Date Inspector � e No. o — � Fee BOARD OF HEALTH TOWN OF BARNSTABLE 2pphrattou jFor Veil Con5tructton Vermtt Application is hereby made for a permit to Construct(�), Alter( ), or Repair( an individual well at: Location-Address — Assessors Map and Parcel nv� (Jl'T•rxc, Ts- -(- s ,o x , koxL o-z� Owner �.. Address Installer-Driller J Address Type of Building Dwelling j I - OtHer 7 Type of Building No. of Persons Type of Well 7 E,� ,,E l ' 1 S C)t��lr� �)C_ Capacity 10 Purpose of Well Agreement: The undersigned agrees to install the afore described individual well in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation-The undersigned further agrees not to place the well in operation until a Certificate of Compliance has been issued by the Board of Health. Signed rr� Date Application Approved y Date Application Disapproved for the following reasons: II' Date Permit No. \,,,�r 1�� �� ' Issued tDate 5 'L BOARD OF HEALTH TOWN[ Of BARNSTABLE Certtftcate of Comphance THIS IS TO CERTIFY,tha_the individual well Constructed( ), Altered( ), or Repaired( ) by Installer at has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation as described in the application for Well Construction Permit No. Dated THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORILY. Date Inspector BOARD OF HEALTH TOWN OF BARNSTABLE- No. VerY Cou.5tructtou Vermtt �,. ��G J � "".G� � Fee Permission is hereby granted to C \ S_ Y`N Installer to Construct P�_ Alter( ), or Repair( an��ndividuaI well at: Street as shown on the application for a Well Construction Permit No. Dated Date / //tf' Approved By Barnstable • /p'pSHETp�y Town of Barnstable 'y``P� � A�-Ame�icacity Regulat ory *'�� ; 1 Services Department f� .TA�h , g Y RAR�NSUI. , 9c\- 6 9: �� Public Health Division AIFb MA�a, 200 Main Street, Hyannis MA 02601 2007 i Office: 508-862-4644 Thomas F.Geiler,Director FAX: 508-790-6304 Thomas A.McKean,CHO February 6, 2003 '(D G Derrick Woodward 164 Coolbreeze Avenue Pointe Claire, Que H9R 357 A, p CANADA ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 . The septic system located at 12 Lisa Lane, West Barnstable MA was inspected on January 16, 2008, by Patrick O'Connell, certified Title V Septic Inspector for the State of Massachusetts. The inspection of the septic system showed that the system FAILED under the guidelines of 1995 TITLE V (310 CMR 15.00) due to the following: e Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool • Static licuid level in the distribution box.above outlet invert due to an overloaded or clogged SAS. You are ordered to repair or replace the septic system within Sixty (60) days from the date of this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF THE B ARD OF HEALTH Thomas McKean R.S. CHO Agent of the Board of Health CULT I C LTA tAA1U*-1006 21 SG OOOZ l03`6 Q:\SEPTIC\Letters Septic Inspection Failures\12 Lisa Lane.doc - -T Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 12 Lisa Lane, West Barnstable MA 02668 Property Address Derrick Woodward Owner Owner's Name information is 164 Ave Coolbreeze, Pointe-Claire Que H9R 357 January 16, 2008 required for ry 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 Patrick M. O'Connell cursor-do not Nil MC) 21 use the return Name of Inspector key. Septic Inspection Services Co. Company Name 189 Cammett Road Company Address Marstons Mills MA 02648 City/Town State Zip Code 508-428-1779 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. Theinspeetion was performed based on my training and experience in the proper function and maintenance ofi,on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 1C340 of=f Title 5(310 CMR 15.000). The system: "r Cld . ❑ Passes ❑ Conditional) Passes t"y ® Fail�� -x? fj ❑ Needs Further Evaluation by the Local Approving Authority , :�-- January 16, 2008 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. 08-15 Woodward.doc•08/06 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 1 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form � Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 12 Lisa Lane, West Barnstable MA 02668 Property Address Derrick Woodward Owner Owner's Name information is 164 Ave Coolbreeze, Pointe-Claire Que H9R 357 January 16, 2008 required for rY every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y, N, ND) in the ❑ for the following statements. If"not determined," please explain. ❑ The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed 08-15 Woodward.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 12 Lisa Lane, West Barnstable MA 02668 Property Address Derrick Woodward Owner Owner's Name information is required for 164 Ave Coolbreeze, Pointe-Claire Que H9R 357 January 16, 2008 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: ❑ Condit ons 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) deterrrlines 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. 08-15 Woodward.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 12 Lisa Lane, West Barnstable MA 02668 Property Address Derrick Woodward Owner Owner's Name information is 164 Ave Coolbreeze, Pointe-Claire Que H9R 357 January required for 16 2008 every page. Cityfrown 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_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. 08-15 Woodward.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments -°�,. 12 Lisa Lane„West Barnstable MA 02668 Property Address Derrick Woodward Owner Owner's Name information is required for 164 Ave Coolbreeze, Pointe-Claire Que H9R 357 January 16, 2008 every page. CitylTown 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. 08-15 Woodward.doc•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 12 Lisa Lane, West Barnstable MA 02668 Property Address Derrick Woodward Owner Owner's Name information is required for 164 Ave Ceolbreeze, Pointe Claire Que H9R 357 January 16, 2008 every page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] 08-15 Woodward.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ., 12 Lisa Lane, West Barnstable MA 02668 Property Address Derrick Woodward Owner Owner's Name information is 164 Ave Coolbreeze, Pointe-Claire Que H9R 357 January 16, 2008 required for ry every page. City/Town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage N/A Well Water 9 ( Y 9 (gpd)): Sump pump? ❑ Yes ® No Last date of occupancy: Unknown Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.).- Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): 08-15 Woodward.doc•08/06 Title 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 12 Lisa Lane, West Barnstable MA 02668 Property Address Derrick Woodward Owner Owner's Name information is required for 164 Ave Coolbreeze Pointe-Claire Que H9R 357 January 16, 2008 eve ry page. Citylrown State Zip Co de Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: Pumped every two years. Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped:Y p gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: Compliance date: 6/15/86 Were sewage odors detected when arriving at the site? ❑ Yes ® No 08-15 Woodward.doc•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 12 Lisa Lane, West Barnstable MA 02668 Property Address Derrick Woodward Owner Owner's Name information is 164 Ave Coolbreeze, Pointe-Claire Que H9R 357 Janua 16, 2008 required for ry every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 1'feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 6 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: 8.5' long x 5.2'wide- 1000 gal. Sludge depth: 3" Distance from top of sludge to bottom of outlet tee or baffle 27" Scum thickness 2 Distance from to of p scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 12 How were dimensions determined? Measured 08-15 Woodward.doc•08/06 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 9 of 15 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments a,.•' 12 Lisa Lane, West Barnstable MA 02668 Property Address Derrick Woodward Owner Owner's Name information is 164 Ave Coolbreeze, Pointe-Claire Que H9R 357 January 16, 2008 required for ry 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.): Liquid level was found at bottom of outlet invert, tees are intact and clear. Tank is structurally sound and could be used with a new leaching system. 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 leve�s 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): 08-15 Woodward.doc•08/06 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 10 of 15 Commonwealth of Massachusetts F W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 12 Lisa Lane, West Barnstable MA 02668 Property Address Derrick Woodward Owner Owner's Name required fo is 164 Ave Coolbreeze, Pointe-Claire Que H9R 357 January 16, 2008 required for every page. Citylrown 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 0 Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Liquid level was found at bottom of outlet pipes. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 08-15 Woodward.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 12 Lisa Lane, West Barnstable MA 02668 Property Address Derrick Woocward Owner Owner's Name information is 164 Ave Coolbreeze, Pointe-Claire Que H9R 357 January 16, 2008 required for y 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: Two 600 gal precast pits. ❑ 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.): Both leaching pits have been full to top, one had been full over top of structure and other had been full to the top of structure. Both were empty at time of inspection. 08-15 Woodward.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Foam Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 12 Lisa Lane, West Barnstable MA 02668 Property Address Derrick Woodward Owner Owner's Name information is required for 164 Ave Coolbreeze, Pointe-Claire Que H9R 357 January 16, 2008 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.): 08-15 Woodward,doc•08/06 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 13 of 15 I, Commonwealth of Massachusetts Qu Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 12 Lisa Lane, West Barnstable MA 02668 Property Address Derrick Woodward Owner Owner's Name information is required for 164 Ave Coo.breeze, Pointe-Claire _ Que H9R 357 January 16, 2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch O-1 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. ell Line 76 4 \ \ \ ♦ Y \ Y \ \ \ \ \ \ A `t Y ♦ ♦ ♦ \ ♦ Y .. Y Y \ Y Y Y Y ♦ ♦ Y Y Y \ Y Y r f�'r�!�'l r /••! / l / / / r /'r r J ! / ! ! / / / ! f / �•r r r � / ! / r / 7 / f / ! /\�\ \� ♦/ / ! ! / ! ! / / 70 102 75 Lisa Lane • Commonwealth of Massachusetts Title 5 Official Inspection Foam Subsurface Sewage Disposal System Form - Not for Voluntary Assessments •'° 12 Lisa Lane, West Barnstable MA 02668 Property Address Derrick Woodward Owner Owner's Name information is required for 164 Ave Codlbreeze, Pointe-Claire Que H9R 357 January 16, 2008 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: N/A 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: 08-15 Woodward.doc•08/06 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 15 of 15 Town of Barnstable OF 1HE Tp� Regulatory Services sa�xsTaB Thomas F. Geiler, Director Mass. 1639. ��� Public Health Division ,erF�MAy� 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. Torn.af BU. � tl$b e P# D►epartenent ti>l Regutetory Services " ' l Public Health-14YiA 11 'note �, N. ` 200`Main Sttegt,Hyanpis MA-Q2601 "IF /' 4 - R i• t - III K } {' ' ;lJ `�;, Tame 1- Fee 1'd SQr .SuabZtty Assessment for ► ewaea ' - ppee ,LOCATION& GENERAL INFORMATION I.beBlteitddkees y � Owner'sNatnc �e�i L `� , r [ i 'f i`GLL �d cal; r t Zf $c, (.av►Q fN.� l� r�. Address Cave b2c !`� 9 J2 Asscssar's Map/Parcel_ 1 l'� -�O Bngineer's-Name NBW,COIyS R11G1TON REPAUt ` ;,OC__. Telephone# .L , 7 J 3 f land,.11se ` $i«-eV "� .Slopes(%) Surface.Stoaes Diatanees from.:"Open Wtiteriiody lZl ft Possible Wet''Ana���� ft Drinking Water Wyll �ft w Drainage Way.� 'O0 ft. property L rve ft outer — A. .; SKETCXI,;istreet.nathe,dimensions of lot,exacClocations of test holes&perc tests,locate wetlands"�n proxir+�ty tholes) I , G1 L-,sA L-AtAj l Parent material SgeolQ8tc) �srl ~4 f! .QrrJ i^ Depth to Bedrock . Depth ttl:t3roundwater Standing,. in Hole: / Weeping from Pit F►aCa Estimated Seasonal:High Groundwater PE1'E ME NATION FOR SEASONAL HIGH WAr'T .Y.>.;. Method:Used Depth pbservod:standing in ohs,hole: r in, t)epth.to sail tnOttGll •F� In; Depth[o weepuig,frvm.aide of oos,hole, im Oman water AdJttstment ft Index Well.# Readin Date: Index Well,level Ad), thctOr A, � y , -0 eevation y . ;, y . f Y $ Me# i Time 1 Depth of i'crc fl U TYme ut 6' Start Ere-soak'nme® Z ` i mime(9"41) Bnd pfe-soap z 3y s Rate Mm:Meh � �Site SUIOWity.Assessment: Site Passed 24 Sun Failed: Add nonal.Test#ng Ne�d�d.(1f�1`l�;�_� M Original- Public 1#ealth:�ivision' Observation Hole Data To Be Completed on Back 0 if percot tion est is to be conducted within 1001 of wetland,you must,€ > F Barulstable Cbnservation Division at least one(1)week prior to beginning. n.ionvr►FkpRbr`RhpdA nnr i DEEP OBSERVriTION MOU LOG Hole# l Depth from, Soil Horizon Soil Texture .Sdii Color, soil Other'. Qutttut�„Stogcs (Ivlausnllj: MottUng (S, : ,Boulders. CJ AF. ':, C�sf .b• '.t �"ihl Y�`� tom. •� 1 P9 OERMVA HOLE I ©G Hole TION # w, Soil Horl�on .Soli Tezt�re Soil dolor Soil ;Qib Surhtee(ia.) (USDA) (Mansell) Mottiidg .(Structute,St�rtes,BoplQetb, / .--7 i ( e L4 A . -77 i . ....:... . ...: S QESERVATION H0L 1 -QG Hoy# zi ',4ttil{ tHxda <Soil`CFacture Soil Color. boil.:' f Sufa-(ta) (USDA) (Mansell) Mottling (Structure;Stones,,9ouldors. b. �FSRVATION HOLE LOG Hole# Depth irortl Soil f3Fxfzon Soil Texwre Soli Color gaU pr Surf$te(Iq� (USDA) (Mansell) Mottling (S..h4,1 vcture,Stoltp;Boulders; , ' Flood II18tl ;Iiiate M$n• _ r. �tp ; Above �tlbodonndtry rNo Wthipu598.�+esrbouridary Nor Yes, . x; k i t�llloa�dlboundary No Yes , I e$of 1eacstr p4tr Feet op naturally occurring pervious materiel exist in all areas:observed thrpughoutitha ar.. prepiasetirt�ot<the soil absorptlon'system? y If at,what is the depth of naturall (date)occurring pervious material-? t rs rtl that on q�t I have passed the soil evaluator examination approved by the '� artment of Lnvlron mental Argtectiorr and.that the above analysis was performed-by me totrsistenr�i the`regiured training,expertise and experience described'in 10 CMR 15 017 , .: � r S SJgnature ,�'�t.-��� Dacer�"p O K4 z #rs ti I rJ 1 TOWN OF BARNSTABLE LOCATION /�? L/5,4 ZVwe SEWAGE # SOD$-097 VILLAGE /!/`57 sroble— ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY /000 LEACHING FACILITY: (type) H-10 1�!n 01F� C-r (size) 3/,7 X /42 NO. OF BEDROOMS BUILDER OR OWNER PERMIT DATE: 3'!Y-O COMPLIANCE DATE: 3-/9-OS Separation Distance Between the: N 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) ^eet Furnished by .,, •• �. � �' c ; � v �� � S W 6, L_ FtroyT 5 y' �� O �o17�FF�fS'er �nSpi_=Grog Pa�f �� \� L��-G I G.islq i No. IL "Q Fee ` THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes Application for �N-5po!gar �&pgtem Con0tructiou Permit Application for a Permit to Construct Repair(G4�- pgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No./.� ��q' b~{ Owner's Name,Address,ajgO Tel.No Assessor's Map/Parcel „4-0 Installer's Name,Address,and TF1.N5� Designers Name,Address and Tel.No.SOS.. ✓oscj0,�,�D.c�l3�ar�os k 1E�xe�vrscri�► �vmnc- .1 "difrwx off Af Type of Building: ' Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder ( ) Other Type of Building f' No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 3 (� gpd Design flow provided 3 ,5 gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) sTiyt/� •5(�`� �� /G 1z �{--QO {�C/� Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signed Date 3—1 4f'D Application Approved by Date 3— t—f —0 Application Disapproved by: etG; t Date% �— for the following reasons +ti.� �' .y Permit No. �0 C l Date Issued v 3————— — - 1011 -5L :�—/ No. 9009 Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes ' ZippYicatiou for �Dtzpogal 6ipMem fCous;tructtort'Vermit Application for a Permit to Construct(v)�Repair(,�.)-Upgrade( ) Abandon-(` ) n'Complete System ❑Individual Components Location Address or Lot No.l 1 L/}r2 '{k� Owner's Name,Address,and Tel.No.�/ r fjrrSt<4�/� Uerv/Cl� Lt/cauG�u��N�f Assessor's Map/Parcel /� / Goy ,fir•ce Z� oi/a%� c././Fis�!' !y� r -e �` Installer's Name,Address,and Tel.No. S6� O-�` �` Designer's Name,Address and Tel.No.3��"` )o.i4)G J e G?are as f � if- �. �iH uv`l.rfc-' &'� Cwa� .a 11 /2..F' Gl-`lcs��'T,�.��s �-��/�' �� �i! G�oss/i-c%•l/�i Sri=},T-ff/� Type of Building: Dwelling No.of Bedrooms ' Lot Size sq. ft. Garbage Grinder ( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 3 3 o gpd Design flow provided 3 5j gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. .Description of�soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. t Signed Date Application Approved by ✓ ( Date Application Disapproved by: Date for the following reasons rf .r Permit No. 6LOO -^ D ► Date Issued 3, y 0 y THE COMMONWEALTH OF MASSACIAUSETTS BARNSTABLE, MASSACHUS19TTS Certificate of Compliance THIS IS TO CERTIFY„that the On-site Sewage Disposal System Constructed ( ) Repaired ( e--) Upgraded ( ) z, t' Abandoned( )by ,A-1 /2. at / f c 14 /t-�Gs Z�- �� has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. Od� 0 dated 3't14'0� Installer :•{aG ��r / +ice ,�f Designer /,"s>*cf, ;,. .c.Gri<�.✓ Cyus^t�S #bedrooms _'' Approved des'.grt fl t gpd The issuance of this permit shill not b}c irues a guarantee that the system ill functio .de gne Date 3 Inspector -------1l---- -- No. ;)oo 097 Fee IOU THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION—BARNSTABLE, MASSACHUSETTS 1wtopogar *p!gtem Con5tructton Vermtt Permission is hereby granted to Construct (G ) Repair Upgrade ( ) Abandon ( ) System located at /:' // '6 Z and as described in the above Application for Disposal System Construction Permit.The applica ecognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Construction must be co leted within three years of the date of thisit� Date 3 " f L-t— d Approved by F, 03f18/2008 18:37 5084775313 ENGINEERING WORKS PAGE 01 Town of BarnsUble Replatory Services Thomas F.Goiiler,iDirector DIAOM I WL $ Public Health Division Thomas McKean,Direclor k 209 Man Strut, Hymwk4 MA 02601 Otte 5!0�84162-46" Fax: Sd8-T9�04M ? Date. /8 leySgMpreradw 6W-0. mommeswommw Instnllar a 2obw Cerdilwd-40 F� fe4-e0-7' MG95rr}" �15. V 1�I gLe8r:., 4 Wnrk3 I m. Y Qr-.slyrlts M �11s Y14 !9 t- , on %A 0 '-C..S" was issued] permit it to install a 4� V (daft) (installer) Septic system at 12 L "CA L In e r NJ, RQ r1-1 based on a design drawn by 3/,3 a I certif that the septic system referenced above was installed subssmrtially accord' w are design, which may iaclu�minor approved dMgp such as lateral relocation Qf distribution box and/or septic tank. Stnpout (if required) was hivected and the soils were found satish►ctory. I certlify that the septic system referenced above was installed with major changes (Le. g mtaer than 10' lateral relocation of the SAS or any vertical f may Component of the septic system)but in accordance with Stme&l.oes revision or Certified as-built by designer to follow. Stripwrt(if r+ecpi the soils wem found satisfictory• PETER T. yGr NcENTEE CIVIC. No. 35109 iftstalWs S e)' ` (Designees Signature) (Mx giw;Stamp ) pLLASE TO BARMT x C TH DIVMON. filMiUED T CARD BY BARDWARM PUBUC HIAMM DIVISION- 7RAMEYOU, ai Ada LOCATION SEWAGE PERMIT NO. i-.o-' A LISA LORE: YIL.LAGE W C ST '9 A9,WS q(3LjE G INSTALLER'S NAME A ADDRESS 3 � 3000 B U I L D E R ON M- ,-H Cr,)Sg 1-�0 � S —E p's �flRW cH nlaSs � pvv �.t�Qp '� c�9flwAQ..b DATE PERMIT ISSUED Zl ' -pEr"IN.) DATE COMPLIANCE ISSUED m W c L,l, No • THE COMMONWEALTH OF MASSACHUSETTS _ BOARD OF HEALTH ®`,� t•1................OF.. . ........� - l. T .BL ................- - J�c C Appliration for Dispaiial Works C9onstrudion Vrrnnit Application is hereby made for a Permit to Construct ( or Repair an Individual Sewage Disposal ( ) g System at: W eSk ( -�- L..— LOT -.w�•.Loc tioa• or Lot No. ................___-�- �/<<.�........... �o c�. .......... .....................�-� w/ C/ / A d ess ,p ..................................._......�.�..:.....t..............i.G ..P..YJ.... ��./.L .L?z.. ./ll.!1 f. .................. Installer Address Type of Building Size .....Sq. feet ., -Z Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Other—Type T e of Building No. of persons............................ Showers da � YP g •-------•.........................:........ --- ( ) — Cafeteria ( ) Other fixtures,•-.=.'=•......................... •---..............---•------------------...................................................-- Design Flow................... ............gallons per person per day. Total daily flow................3 a....................gallons. Tank— iameter �Dipticsal TrenchLiq No capacty.loA�.galthns---•LengthTotal Length ToDtal leaching •---•-• W - x p° gth .......................sq. ft. 3 Seepage Pit No.......�........... Diameter.....? ... Depth below in1et..3.::.Z...... Total leaching areask 3L _6sq _ft. Z Other Distribution box.(x) Dosing tank ( ) G P p aPercolation Test Results Performed by..............................................*........................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Lt. Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ PG ..................................................r......... -•------ ...- • ........._............................ Descri Description of Soil....................................... � ............................................................................................... W ----------- . -------------------------------•--.-----------. --------------------------------------------•-•--....-•-•-•---------.......-----...-•------•-•---••--.......------.....--------•--........--•--•........................-----•-•--......_..-•-------•••- U Nature of Repairs or Alterations—Answer when applicable............................................................................................... --•-•--•---•--•.............................•-----•-.................---•--......--•---.......------------......-•-------•--•--............................--...................................--••_... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate -of(�Compliance ^s ss ed by th boar�f h th. , rl cat Date App canon Approved By........................... Date Application Disapproved for the f ollourin e°sons:...........................................................•.............-............................... .___ ............................................................................................................•...............•...................................0................. D�...... ....^— PermitNo.........._............0..........----- ....._.._ Issued..................................................... -•- Due ' THE COMMO_ NWEALTH OF MASSACHUSETTS BOARD OF HEALTH . ; ppliratton-fnr a spnsttl Works Ton's#rudiun Hari# Application is hereby made for aPermit-to-Construct ( or Repair ( ) an Individual Sewage Disposal, System at: -_ _ ,--`'; ; ,r � L _S—gLei 4 Li .................... ......................--........................ ._.----•----•---....... ..�_.:._ Location=Address / f or Lot No. / ..- ... ----��-* r t !L I• xitfo �'1 __ 'Owner / �1 Addriess J, W .:... �4 /t/!.�' � !d arc._�1�... ..r#a`...............-1,..• •4__ 1? /at..�../ I7,- .--••- Installer v Address pq Type of Building Size Lot._`h?:. 4^::>...Sq. feet 6 ai Dwelling—No. of Bedrooms.................. .....................Expansion Attic ( ) Garbage Grinder ( ) Pa.I Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) dOther fixtures ..............................•--•--._........._..__........._.............------..................._..---.._............_...._•-••-•••-•--...---•-_.. W Design Flow...........:....•-_ '`!�...............gallons per person per day. Total daily flow................3 :�...._._.__._____gallons. a 1 Septic Tank—Liquid capacity. elez--_gallons Length________________ Width................ Diameter................ Depth................. W `u Disposal Trench—No. - Width.................... Total Length.................... Total leaching area_._ _..._.._sq. ft. 3 Seepage Pit No........%� .. Diameter.._... .�`_.�Depth below inlet_._�'-�`�... Total,leaching area: �,.:_clsq.-ft. z Other Distribution box ( ) Dosing tank ( ) ~" Percolation Test Results Performed by....................... Date............................:........... Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water......................... f=I Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ . -- a ODescription of Soil---....._..-•-• . � ...:.. fi W ................• -----••. ---•---...--••- ---...•--• , ......-------........-•----•-••-----•---••----------...-----•-••-•-----••---•----...----•--................_......._.....---•---• .......... •-----•--•---••---____-___----•----------•----______-_.---•--•----____----------------------- U Nature of Repairs or Alterations— whe ... Answer n applicable._______________________________________________________________________________________________ --•--•-••...................................•-••--•--•-••-...._...... ...................._•-------•---•-••_---•- --...--•-........-----................. ..._.........-•-•.......--••---_. Agreement 1 The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has issued by the board of health. I L Date APP1 cat�A r PP oved By_ -•-------•-.,,,- -,JDate Application Disapproved for the following easons:............................... ...._^............................... ................................•---....— .....--•-. .................. -•----...__ _ ... ._...— Date PermitNo....::................ ........_.......... Issue(L.................................. .- ....._ c THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH I0w n ...OF....... 2.9 ri �a f�/ ................................... ........... .......................... t � ., f9lertif ratr of Toutphanrr - ThIIS��TO"C RTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired 1 tr� � �f...tS ...t by....------•--•--••-•- 1 .... . ........_....... •- ............... -•----•-- Installer at..................... ,,................................ =A `. ..........:.... has been installed in accordance with the provisions of TITLE j of The State .Sanitary Code as described in the application for Disposal Works Construction Permit No :I a._.: -_�_2_:_.__..__. dated....._-:'- 1.. V: ............... THE ISSUANCE OF THIS CERTIFICATE-SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE..:............ .......... ......................................... Inspector.............................................. ............... �4 = !� 1 oa-3 ,--roof. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF. HEALTH :...............OF._.,. ............................ • FEE.... .�......... i psal lurks tunstrurfion filer it Permission Is hereby.grantedj��` to Construct. ()e) or Repair-( ) an Individual Sewage Dispo tj tear+ t at No.•••••-•••-••...---••......._--__• _Llai=...------!t----- ---�-t ..LA; - .�.'....... �� �- Street as shown'on the appllication for Disposal Works Construction ermit.DLo� ........................................ ..tC- 4 g6, 1ti r Bo ealt DATE., . a FORM 1255 HOBBS d WARREN. INC..,,.PUBLISHER.S ,•,,,, _ l•'n N v Williarn's Path g�' r LOCUS ova Ra 5 N 4954'30" E Count 'a 214.15' N em8.4o•E Street ° / o g o � K `u a. Lot ° 70,182t S LOCUS MAP 18 F. EXIST. WELL 1.613 AC NOT TO SCALE Map 111 a Parcel 23 GENERAL NOTES: ti 1. ALL CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL N BOARD OF HEALTH AND THE DESIGN ENGINEER. 61 c 2. ALL WORK AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS OF THE STATE ENVIRONMENTAL CODE, TITLE V, AND ANY APPLICABLE -—-—- --------------- --- -------------- - LOCAL RULES AND REGULATIONS EXCEPT AS REQUESTED BELOW: 310 CMR 15.405(1)(b): N w 1) A 1.5' variance to the 3' maximum cover requirement, for no greater w C3 than 4.5' of cover. S.A.S. shall be vented and H-20 Rated. h6 co to I 3. THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE BACKFILLED PRIOR CO o{'o TO INSPECTION AND APPROVAL BY THE BOARD OF HEALTH AND THE DESIGN ENGINEER, y m i 4. ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING FROM THOSE SHOWN HEREON SHALL BE REPORTED TO THE DESIGN ENGINEER BEFORE CONSTRUCTION CONTINUES. i �� Of MAS 5. ALL ELEVATIONS BASED ON ASSUMED DATUM. f)=k 6. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF PETER T. aJ THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF i HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION. r' CX/$ G�/ i Mc CIVIL � I � CIVIL "' 7. WATER SUPPLY PROVIDED 6Y PRIVATE WELL_ HOUSE i No. 35109 8, THERE ARE NO PRIVATE WELLS WITHIN 150' OF THE PROPOSED S.A.S. SZE��`� 9. ALL AREAS CLEARED FOR CONSTRUCTION SHALL BE RESTORED AS PROPOSED S.A.S. I ` G�� AGREED UPON BY OWNER AND CONTRACTOR OR AS OTHERWISE 35 DIRECTED BY THE APPROVING AUTHORITIES. Ir- _ '� .31�2 fO� 10, IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY THE --} -i l 71 THE LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO BEGINNING '9 ? T _31 �,",� CONSTRUCTION. � OWNER OF RECORD o 1 1• WHERE REQUIRED, CONTRACTOR SHALL REMOVE ALL UNSUITABLE SOILS 252.87' DERRRICK WOODWARD IN THE AREA BENEATH AND ON ALL SIDES OF THE S.A.S. AND REPLACE S 4827'43" W 164 COOLBREEZE WITH CLEAN SAND AS SPECIFIED IN 310 CMR 255(3). POINTE CLAIRE, QUEBEC 12, AREAS REQUIRING STRIPOUT OF UNSUITABLE MATERIALS SHALL BE CANADA INSPECTED Y HEALTH DEPARTMENT I Edge o/ povemenl _ B E RTMENT PRIOR TO BAC4<FILL. USA LANE PROPOSED SEPTIC SYSTEM UPGRADE PLAN 12 LISA LANE, WEST BARNSTABLE, MA Prepared for: Derrick Woodward, 164 Coolbreeze, Pointe Claire, Quebec Engineering by: Surveying by: SCALE DRAWN JOB. NO. SEE SHEET 2 OF 3 Engineering Works WARNER SURVEYING 1"=40' P.T.M. 133-08 L-------__------_----___--__—_------_ -__� 12 West Crossfield Road 22 Long Road 20 CALE Forestdole, MA 02644 Harwich, MA 02645 DATE CHECKED SHEET NO. S � (508) 477-5313 (508) 432-8309 3/13/08 1 of 3 1 11 EXISTING SEPTIC TANK ^� Lot a TOP OF TANK, EL.=88.38E o INV.(OUT)-87.0t 70,182E S.F. 1.61t AC. � o x Qom• a �° �1 �� 111 a Map fC2 ,� , ,(D Parcel 23 / + N 1 gyp+ 90 M ({ Deck �n CZ ' tS " EX/STING/// A f �' 0000 WOODED / ' + -..:Deck j/�?OF=97.46,"/ / ni EXISTING LEACH PITS / , (Assumed Datum)��/" TO BE PUMPED, FILLED W/ P SAND & ABANDONED J I 35 9�6 11A + .9 o g4- 'r� .�1�- �If„. �y ` � - pip --r TP-1 � -2 VENT Zh �' v S' - S _ -� o I, r 252.87' - " o i 90 • / 9 -�— S 48 2743" W _ - 3f, 1 + �9 61> c9g g1 1 Edge of pavement 90-- LISA LAINE LEGEND 92� 92.47 P /SET -• - 98 —— EXISTING CONTOUR x 100.98 EXISTING SPOT GRADE PROPOSED SEPTIC SYSTEM UPGRADE PLAN W EXISTING WATER SERVICE BENCHMARK MAGNETIC NAIL SET 12 LISA LANE, WEST BARNSTABLE, MA G EXISTING GAS SERVICE EL.=92.47 (Assumed) Prepared for: Derrick Woodward, 164 Coolbreeze, Pointe Claire, Quebec _O.H. W._ OVERHEAD WIRES Engineering by: Surveying by: SCALE DRAWN JOB. NO. TEST PIT EnginwidIngWorla ARNER SURVEYING 1"=20' P.T.M. 133-08 12 West Crossfield Rood 22 Long Rood DATE BENCHMARK Forestdole, MA 02644 Harwich, MA 02645 CHECKED SHEET NO. (508) 477-5313 (508) 432-8309 3/13/08 P.T.M. 2 of 3 { 4.. Z. NOTE: TO PREVENT BREAKOUT, THE PROPOSED j FINISH GRADE SHALL NOT BE < EL:83.33 ' FOR A DISTANCE OF 15' AROUND THE 5-4POLYSEAL. " PERIMETER OF THE S.A.S. 22" PROPOSED TANK PROPOSED D—BOX PROPOSED S.A.S. 4" 4" INSTALL RISERS & COVERS OVER INLET & INSTALL RISER & COVER INSTALL INSPECTION PORT OVER END UNIT T.O.F. OUTLET AND SET TO 6" OF FINISH GRADE IF SET TO 6" OF GRADE EXISTING TANK IS GREATER THAN 3 FT. BELOW GRADE F.G. EL: 87.8(MAX.) VENT ; F.G. EL.=88.8t F.G. EL: 87.5t N F LO MAINTAIN 2% GRADE (MIN.) OVER S.A.S. 7kT�� INSPECTION L 80' L = 7'(MAX) PORT ® SCH4 $CH4 (PVC H-20 RATED Section 4"SCH40 PVC 4"SCH40 PVC N Top View , TO ,a INVNV ERTPER EXISTING 48" LIQUID D- BOX LEVEL3GASABAFFLE INV.-83.67 INV.=83.50 �4 ROWS OF 5 UNITS AT 6.33'/UNIT = 31.7' • • PROPOSED D—BOX INV.=82.96 4 OUTLETS (MIN.) SOIL ABSORPTION SYSTEM (PROFILE) EXISTING 1000 GALLON SEPTIC TANK INV.=87.00t ESTABLISH VEGETATIVE COVER EXISTING BACKFILL WITHmttEAN NATIVE OR �°'� 75" PERC SAND TO TOP OF CHAMBERS NOTES: 1) D—BOX SHALL BE SET LEVEL AND TRUE TO GRADE ON A MECHANICALLY COMPACTED SIX INCH CRUSHED BREAKOUT=TOP STONE BASE, AS SPECIFIED IN 310 CMR 15.221(2). TOP ELEV.=83.33 2) INSTALL INLET & OUTLET TEES AS REQUIRED. INV. ELEV.=82.96 3) GAS BAFFLE TO BE INSTALLED ON OUTLET TEE BOTTOM ELEV.=82.00 II III IIIII�II AS MANUFACTURED BY TUF—TITE, ZABEL OR EQUAL. 2•8' 4) CONTRACTOR SHALL VERIFY ALL EXISTING PIPE 4' MIN. ABOVE BOTTOM OF r" 76 �'1 INVERTS PRIOR TO CONSTRUCTION. T.P. EXCAVATION OR G.W. EFFECTIVE WIDTH=11.2' EXISTING SUITABLE PROFILE NO G.W., EL=75,2 = MATERIAL SEPTIC SYSTEM PROFILE WITH ROWS O NO EPARATION BETW E)NAED EACH ROW &ENOUNITS STONE TYPICAL SECTION 16" N.T.S. N.T.S. 11.2" SOIL LOG -�- �- DESIGN CRITERIA DATE: MARCH 11, 2008 (REF#12,144) --34"----� SOIL EVALUATOR: PETER McENTEE SE, PE SECTION END CAP NUMBER OF BEDROOMS: 3 BEDROOMS WITNESS: DONNA MIORANDI IRS SOIL TEXTURAL CLASS: CLASS II HEALTH AGENT 16"" HIGH CAPACITY (H--,20) BIODIFFUS R UNIT DESIGN PERCOLATION RATE: 10 MIN/IN ELEV. TP- 1 DEPTH ELEV. TP-2 DEPTH 86.2 A 0" 87.6 0" MODEL 16" HICAP DAILY FLOW: 330 G.P.D. SANDY LOAM FILL LENGTH 76" NOTE: UNIT CONFIGURATION AND AVAILABILITY SUBJECT DESIGN FLOW: 330 G.P.D. 10YR 3/3 EFFECTIVE LENGTH 75" TO CHANGE WITHOUT NOTICE. PRODUCT DETAIL MAY GARBAGE GRINDER: NO 85.7 6" 86.0 191, DIFFER SLIGHTLY FROM ACTUAL PRODUCT APPEARANCE. B SANDY LOAM A SANDY LOAM SIDE WALL HEIGHT 11.2" LEACHING AREA REQUIRED: (330) = 550.0 S.F. 10YR 5/8 10YR 3/3 OVERALL HEIGHT 16" .60 82.7 42" 85.6 24" OVERALL WIDTH 34" 4640 TRUEMAN BLVD EXISTING SEPTIC TANK: 1000 GALLON CAPACITY (RECORD) C 48" B SANDY LOAM 13.6 CF HILLIARD, OHIO 43026 10YR 5/8 CAPACITY 101.7 GAL SYSTEMS, INC. PROPOSED D—BOX:: 1 INLET, 5 OUTLETS (MINIMUM), H-20 RATED PERC 82.9 C 56" ( ) ADVANCED DRAINAGE COARSE 60 USE 4 ROWS OF 5 — 16" (H-20) ADS BIODIFFUSER UNITS SANDY LOAM COARSE PROPOSED SEPTIC SYSTEM UPGRADE PLAN 2.5Y 5/4 4 5Y 5/ SANDY. M 1 2 LI SA LANE WEST BARN STABLE MA W/ NO STONE FOR AN S.A.S. WITH DIMENSIONS 1 1 .3' x 31 .7' ,os� GRAVEL + BOULDERS 10% GRAVEL Prepared for: Derrick Woodward, 164 Coolbreeze, Pointe Claire, Quebec SIDEWALL AREA: NOT APPLICABLE BOULDERS BOTTOM AREA: (GENERAL USE APPROVAL FOR 4.7 SF/LF OF BIODIFFUSER) Engineering by: Surveying by: SCALE DRAWN JOB. NO. 20 UNITS x 6.33 LF x 4.7 SF/LF = 595.0 SF 752 1 132 76.6 1 132" EnginftdngWorkr WARNER SURVEYING NTS P.T.M. 133-08 PERC RATE 10 MIN/IN. ("C" HORIZON) 12 West Crossfield Road 22 Long Road DESIGN FLOW PROVIDED: 0.60 x 595.0 = 357.0 GPD NO GROUNDWATER ENCOUNTERED Forestdole, MA 02644 Harwich, MA 02645 DATE CHECKED SHEET NO. (508) 477-5313 (508) 432-8309 3/13/08 P.T.M. 3 Of 3 P. —1 VM n1l 7 7 mill" -Z.*Z t� N L Z, Acj-1 f::7r I t>IS or T ' => >t r, JE L L j�7 E��OLA 1p> K. $CA �5 u A Cr A "I T�i ts rl -7"1 Ile �z 7- 6�A �7 C>C6 �7, jE y C_: _G 4 ELI'r IG F ACtt�;t 7 ',CA L AC A T, 1=L6 VA i L j4 6 atMo"Q Akl I �L E F IE Aj iL T L LC z, k 41 Pc%.k, A ty )G AL 5C Q no ST p e G t-A t:)F I /�, A r-i�!>164 Z _A0 Lt-0 _�7 01F FCjt.L T 1;�:A C C6 >:,W I 0 it c> i�rk A bV7 VtbT, G isZ7 6T f 4L I ly V, 4 C:5'1 A C 4! MA 0(:�o G L oAVr 'A�l tl/4 Au_ u MES A W -T-Art C) To L I L 3,p Tc 14 mim M rF Lt M OST 8M Auk -0 I-low M L ro m �T w" Elpf zt.6 A( lo� T L PROJECT TIA '11�tA 6A LA N1 C7 r�A IL T I(S ?,A e T jA -0 G E: IET TITLE DRAWN BY REVISED 7aY Inc. A OF M:�OTECRA L ANDV NSTRUC YON �02653 (617)259-651 1 BOX 417,ROUTE ga tAfGINEERS ORLEANS,MASS By DA SCALE TE WING NUMBER ST. KEN tj s ALL P/x ---------- G) OTED