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HomeMy WebLinkAbout0055 LISA LANE - Health 55 Lisa Lane W. Barnstable A = 111 011004 a z 1 ' S Commonwealth of Massachusetts o// - oo� W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 55 Lisa Lane Property Address Theodore Hitchcock(owner of record ) " Owner Owner's Name information is required for every West Barnstable Ma 02668 7/20/2017 :;a page. City/Town State Zip Code Date of Inspection ' p; 4 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 Sean M. Jones use the return Name of Inspector key. S.M.Jones Title V Septic Inspection Company Name 74 Beldan Ln. rem�I Centerville Ma 02632 Cityrrown State Zip Code 774-248-4850 smjonestitle5@gmail.com S14522 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 7/20/2017 Inspectors Signature Date " The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 ,�o v'i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments GSM 55 Lisa Lane Property Address P Y Theodore Hitchcock owner of record Owner Owner's Name information is required for every West Barnstable Ma 02668 7/20/2017 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: j 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 M 55 Lisa Lane Property Address Theodore Hitchcock(owner of record ) Owner Owner's Name information is required for every West Barnstable Ma 02668 7/20/2017 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 wM 55 Lisa Lane Property Address Theodore Hitchcock(owner of record ) Owner Owner's Name information is required for every West Barnstable Ma 02668 7/20/2017 page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters ❑ ® due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 55 Lisa Lane Property Address Theodore Hitchcock(owner of record ) Owner Owner's Name information is required for every West Barnstable Ma 02668 7/20/2017 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 55 Lisa Lane Property Address Theodore Hitchcock(owner of record ) Owner Owner's Name information is required for every West Barnstable Ma 02668 7/20/2017 page. City(rown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 gpd t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Dorm Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 7M 55 Lisa Lane Property Address Theodore Hitchcock( owner of record ) Owner Owner's Name information is required for every West Barnstable Ma 02668 7/20/2017 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d well 9 ( Y 9 (gP ))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: vacant 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: 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 55 Lisa Lane Property Address Theodore Hitchcock (owner of record ) Owner Owner's Name information is required for every West Barnstable Ma 02668 7/20/2017 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1500 gallons gallons How was quantity pumped determined? size of tank Reason for pumping: overdue maintenance Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) 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 r Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 55 Lisa Lane Property Address Theodore Hitchcock(owner of record ) Owner Owner's Name information is required for every West Barnstable Ma 02668 7/20/2017 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: system installed 9-1-95 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 5 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Joint were ok, no leaks, vented through the roof Septic Tank(locate on site plan): Depth below grade: 4 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: Years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 gallons Sludge depth: --- t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 55 Lisa Lane Property Address Theodore Hitchcock(owner of record ) Owner Owner's Name information is required for every West Barnstable Ma 02668 7/20/2017 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 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 How were dimensions determined? Tank cleaned at time of inspection 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 cleaned at time of inspection for routine maintenance and should be done again every 2 years to prolong systems useful lifespan. Risers were installed on access covers. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 J Commonwealth of Massachusetts r Title 5 Official Inspection Dorm Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 55 Lisa Lane Property Address Theodore Hitchcock (owner of record ) Owner Owner's Name information is required for every west Barnstable Ma 02668 7/20/2017 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts E W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 55 Lisa Lane Property Address Theodore Hitchcock(owner of record ) Owner Owner's Name information is required for every West Barnstable Ma 02668 7/20/2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): OilDepth of liquid level above outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Distribution box was video inspected and found in good condition, no rot, water level was even with outlet invert. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 55 Lisa Lane Property Address Theodore Hitchcock(owner of record ) Owner Owner's Name information is required for every West Barnstable Ma 02668 7/20/2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® 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.): s.a.s. consists of 8 Infiltrators , s.a.s. was not located. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts W Title 5 Officia l Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 55 Lisa Lane Property Address Theodore Hitchcock(owner of record ) Owner Owner's Name information is required for every West Barnstable Ma 02668 7/20/2017 page. Cityfrown 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.): Privylocate on site plan): ( P ) Materials of construction: 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °p 55 Lisa Lane Property Address Theodore Hitchcock(owner of record ) Owner Owner's Name information is required for every West Barnstable Ma 02668 7/20/2017 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 to All 131 Z ° A2 �v 6 Z y5'� A3 z►'e, '� 133 yv t5ins•3113 Title 5 Official Inspection Farm:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 55 Lisa Lane Property Address Theodore Hitchcock(owner of record ) Owner Owner's Name information is required for every West Barnstable Ma 02668 7/20/2017 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 high ground water: 12'+feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Groundwater elevation was determined by accessing Town of Barnstable groundwater contour map. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts H W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 55 Lisa Lane Property Address Theodore Hitchcock(owner of record ) Owner Owner's Name information is required for every West Barnstable Ma 02668 7/20/2017 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file i, 15ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 ENVIROTECH LABORATORIES,INC. MA CERT. NO.:M-MA 063 8 Jan Sebastian Dave Unit 12 Sandwich,MA 02563 (508)888--6460 1-800-339-6460 FAX(508)888.6446 Client Name Scannell Well Drilling Location 55 Lisa Lane, Address 108 DeGrass Road W.Barnstable,MA Mashpee, MA 02649 Sample Date 07/20/17 Collected By DS Sample Time 10:15 Sample Type Drinking water Date Received 07120/17 Lab Order Number DW-172443 Well Specs sot � t>*s ass Y?�7 g^'-Y rtr"xz t94.pTF l(m t y iin sr� n, �at0° 'QllOete., r�'`j a.Qrlecte{l';�'f 3Y '`�`u'3d" $V Yx�ti`• � a'' VO �tne �hT''r '' k i "" r Jtp a J b .� •t.- Y +e5 �'A _ t,.t 9 mr' .` 1re �!�► _ 0T/2Q - �,... � t -� .....xew- Yt:: R., .Y•+.v a a-. t='`x,at!`r,�. Y��,....a....R,+! r �nl �?'-...�i'__. $,''u-. Analysts Requested Uirits Recommender)Limits Analysis Result Method Date Analyzed Analyzed By Total Collfonn CFU/100mL 0 0 SM9222B 7/20/2017 MC _... __..._ PH pH units 6 5 8 5 6.07 SM 4500-H-B 7/20/2017 LLT— o ._ —._ _...._._..Y_.��_ h_..a__—______—...._. _._ S ecific Conducfance� ----�-- _P . T_„ ...,, _e umhos/cm 500 189 EPA 120 1 7/20/2017 LL Nitrite-N mg/L 1.00 <0.006 EPA 300.0 7/20/2017 Nitrate-N mg/L 10 0 3.91 EPA 300.0 7/20/2017 LL Sodium mg/L 20 0 22 EPA 200.7 7/21/2017 BCL* Total iron mglL 0.3 <0.10 EPA 200.7 7/21/2017 BCL" _ _ _ Manganese mg/L 0.05 <0,025 EPA 200.7 7/21/2017 BCL* Comments: pH is below recommended limit and may have corrosive characteristics. Sodium level is not a health hazard. Water meets EPA standards and is suitable for drinking for parameters tested. i Date 7/21/2017 RorraldJ.Snarl Laboratory Director x 4 i C ti S (p4' K .7. i' I BRL=Below Reportable Limits 'See Attached Page 1 of 1 aCertieation is not available for this analyze for polable water sainples.. Er I_ TOWN OF BARNSTABLE LOCATION // / t j S�,[._l _ ,L.GtI'IP � _t°/�,r,I/)f'1 SEWAGE # - VILLAGE J4,�6Sf 1�aY 6 h�p ASSESSOR'S MAP & LOT- INSTALLER'S NAME G PHONE SEPTI� TANK CAPACITY LEACHING FACILITY:(type r r (size) A .NO. OF BEDROOMS_ PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER 1 P b/j C-yC,� DATE PERMIT ISSUED- DATE COMPLIANCE ISSUED: 9- 1- q57 VARIANCE GRANTED: Yes No i —�rCQlccce. _ A3 ' 3 a� F'ront� A A5 A b Q I = aJr t 77 - za= a(0' $3 -a`} , oa g5 = o.to 5 No.--------------5-- Ede-- =S-=-©u BOARD OF HEALTH TOWN OF BARNST�►B1. E Zipp[icationArVe[C Con0ructionpermit Application is hereby made for a permit to Construct ( ), Alter ( ), or Re air ( )an individual Well at: Location — Address Assessors Map and Parcel CIO C ------------------------ CL Owner Address Installer Driller Address Type of Building Dwelling ---------------------------------- Other - Type of Building------------------------------ No. of Persons--------------------------__—_____________ e,�P Type of Well— —--——---- --------- Capacity---— - -- ——-- - —--—- Purpose of Well %`- c.1-_1�'7('--------____-- Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation — The undersigned further agrees not to place the well in operation until a Certificate .of-Compliance has been issued by the Board of Health. Signed U - ------1---- --- --- - ----$�-1�------- date Application Approved By `%2%�� ��i,ry -- r4l 6 - - �— - — ate Application Disapproved for the following reasons:--------------------------------------------------------- -_________ -- — -- -------------------------------------------- - date —- Issued --- — 1 -�- --- — --- - Permit No. --------- -- -- date BOARD OF HEALTH TOWN OF BARNSTABLE (Certificate d)f (Compliance THIS IS TO TI , That theJ II dividuaI ell onstructed (:/), Altered ( ), or Repaired ( ) b �- GINNC�.I/ /l_ /lw -------------- -------------- - -- ---------------------------------------------------------------------------- -------------- ` ^ Installer has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well rotec ion Regulation as described in the application for Well Construction Permit No.=l-S--- --__Dated THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE- --- ——— -- ------ ----- Inspector---------------- t ,_.,.y*Y'r'7�,�-._�.ty.J�,�,-.yf'F. Ede—� • m No.-==---- ------ c , ----------------- ------ BOARD OF HEALTH' TOWN OF BARaNSTABLE Applicat ion ArVe[[ Congtruction3permit Application.is hereby made for a permit to Construct ( ), Alter ( ), or Re air ( )an ind�l Well at: Location — Address Assessors Map and Parcel - -� -------------------------- - - - - n -- - --- -- - - Owner � � Address / f1 -- -------------------- �J Installer — Driller Address Type of Building t Dwelling_IL,,�-K------------------------------------------------ Other - Type of Building ------ ' No. of Persons----------------------------------------- Typeof Well— --- -- —,- -- ----- ------ Capacity---------------------------------------------=-------- Purpose of Well ..------------ Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town.of.Barnstable Board of Health Private Well Protection Regulation The undersigned further agrees not to place the well in operation until a Certificate .of Compliance has been issued by the Board of Health. Signed -=—-- --—- - ------- - - � 10 ��--------- date Application Approved By- 0" - t date Application Disapproved for the following reasons:= -=-------------—------------------------------------------------ ------------- - ----------— ------ -- — ---—-- - - - - -- - - - -------------------------------------- date Permit No �--- ------- Issued------ -- ---.�6 --�—'J-------------------- '�' date F BOARD OF HEALTH TOWN OF BARNSTABLE Certificate Of Compliance THIS IS TO CERTIFY, That the I dividual Well Constructed (,,I; Altered ( ), or Repaired ( ) r �{� Installer - - ---------------------------------------------------- has been installed in accordance with:the provisions of the Town of Barnstable Board of Health Private Well rotes ion No. SPS a�ts Regulation as described in the application for Well Construction Permit No. - ------------------------Dated---- - - ---------- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. f jDATE---------------—= —-- — -- - ——- Inspector------------------------------------------------------------------------ i BOARD OF HEALTH TOWN OF BARNSTABLE Yell CongtructionA9ermit J� G c7 No. ---- - ------I --� -- Fee---- Permission is hereby granted= 1j Ca=" to Construct ( i-J, Alter ( ), or Repair ( ).an Individual Well at: No. _Lv 7'------J_-__/ZS AA u. . — —- ------—---------------------------------------------------------- Street as shown on the application for a Well Construction Permit i E No. Dated--- s , �QIr' Board of Health DATE---- — --- -- -- -- — - r A ' _zz�. c! r 0 s xA= 1- -6 8 ` L' J l I 1 TOWN OF BARNSTABLE V LOCATION,SS: Lane LxkfnSDYI SEWAGE #�� VILLAGE 14,�Sf (j'1; ASSESSOR'S MAP & LOT-,,I- INSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY:(type ►" r (size) NO.. OF BEDROOMS:_PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER IPd #jL olpCk DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: 9- 1- 95 VARIANCE GRANTED: Yes No R =a4' *.F�r� lace Ra= as ' Front M 6 A5 l 6q' At, - too' A -� IBA = as ` I83 =a1 ' °o , s4 = 33: b' 0 3 b5 = 4o.t 5 b ASSESSORSMAPN 67 A PARC8.N0�.0 .� THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE ,2lpphratiall for Db3p t ial WI ork,6 Tontitrurtion Vrrmit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at Z. .............. �✓ -----x=---- ----- -------------------------------------------�--y--------...----------------------------------- I;or,tion-Address or Lot No. ------------ ------?-.. � �!/��.-�0 a :€ Owncr dres J. Installer Address U Type of Building Size Lot------ Z o 41 H+e St- ►-, Dwelling— No. of Bedrooms_____________ -------------•.__.---.--...Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ____________________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) d Other fixtures Design Flow-----------------------------Sb..-•--.gallons per person per day. Total daily flow__.5� ?___----___-_________•-- -___ _gallons. W . - WSeptic Tank—Liquid capacitvl�,0.gallons Length_fd=__U__'_ Width__,S_.-,7_-. Diameter._.:------- Depth_ .-_..... x Disposal Trench—No. ___. ............. Width__ /.............. Total Length._-0's_'-'------- Total leaching area_.4,_X$--.--sq. ft. Seepage Pit No........ ............ Diameter-------.------------ Depth below inlet....._.............. Total leaching area..................sq. ft. Z Other Distribution box ( ✓) Dosing tank ( ) Percolation Test Results Performed by..C.1Y __ S s?S___. . �_�.......___ Date__ =.! _Y3................ � Test Pit No. I_ _.___z----minutes per>nch Depth of Test Pit---/S___--------- Depth to ground water-..-----.................... f� Test Pit No., 2................minutes per inch Depth of Test Pit.................... Depth to ground water------------------------ --------------------------------- •------------- .-------------- •----- x Description of Soil----- 7 � ...... o !.- �'C-' -'-`rr`2 '�'✓'� U --------------•--------------------•---------------•--------------------------------------------------•-----------------------------•-------.._..-------•--------...---------------------------------••- W -----------------------------------------------------------------------------------------------------------------------------------•••-----•-•-•----•-••---•-•----•----•-•-••-••--.....••........--•--• U Nature of Repairs or Alterations—Answer when applicable.__________________________________--------_____________________________________________________ ....--•........................................................................•-•-•----.....__..........---...---••----........._ ........---.................. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the 'State Enviro . ental Code he ersigned fu ther agrees not to place the system in operation until a Certificate of Comp an e has been i su d t e board o e h. Signed ---- ---- '/./..'.1:.J.. fD Application.Approved B ...:::.. ..........--------------- ::..... - G �' < G mj Dare Application Disapproved for the following reasons: --- -------------- -------_...._------------------------------------------........-------------------------------------- - - ---------- ------------------------ ------------------*------------.--- Permit No. ... - .�.. ------��---------- Issued ..._ ~--- w ......... Date No........ - C / /cs0'. r ------ FR$........ ... ........ 4LHE COMMONWEALTH OF MASSACHUSETTS BOARD OFF HEALTH TOWN OF BARNSTABLE Appliratiou for Mirpniiul 'Wor1w C omitrurttnn rrmit Application is hereby made. or Permit to Construct (1 ) or kel air ( ) an Individual Sewage Disposal . System at: / Location-:\ddres=.: or Lot No. i ........ 11---.e'` '! .r. ------------------------------------------ ----- ----- �.�,A+!�R./1:1 :!�. /.Il.:.. �.►�.. As .. .,+._;�_ Own t - 1 Address -------------------j_. . .. .• . 4 nw— PQ Installer •s�/ii/�'�1f.J�/ _ Address UType of Building V., Size Lot-.--_.Z_4.� .. .Sq feeat_ .., Dwelling— No. of Bedrooms------------- --------------------------Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ---------------------------- No. of persons......____.----------------- Showers ( ) — Cafeteria ( ) Other fixtures ------------•-----------•------------•-•-------------- , W Design Flow-----------------------------4-of_-__--gallons per person per day. Total daily flow----4�4.6.-------------------------,......gallons. WSeptic Tank—Liquid capacity_J�QgalIons Length__/e=./,A°- Width.-_t, F---- Diameter____- ----- Depth_.n_7.... x Disposal Trench—No. -----/------------- Width---//_------------ Total Length___57K'._..__ Total leaching area...<�?_5......sq. ft. Seepage Pit No..................... Diameter---------------..... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( v� "Dosing tank ( )_. - , Percolation Test Results Performed by_, .......... Date___-%' ................ Test Pit No: _--.minutes per inch Depth of Test Pit----1�- -.--__ Depth to ground water........................ LET4 1 Test Pit No. 2.........:..:..minutes per inch Depth of Test-Pit..................... Depth to ground water........................ W > ................... ................................................z.___........_......_._...:.:......._.__._.__...._......._._.._...._........._....._. x Description of Soil.......�.-.•ws......... s! f� _s(_ � .�/ U ..................•-'---------............... ........................................ -••------------•--•--•--------------••--•------••-------••---•'---------•--...-----•............-••••-........... W .. ---------------------------•-------•--------...---------------------------------------•-----------------•------- ----------------------•------------------------••-------------•--------------• s -_.._. x � .,Z 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 Environ. ental Code=The u,dersigned further agrees not to place the system in operation until a Certificate of Compl>an e�has been issudlie board of 1�}e th. I J Signed ..�:..frJ': _ / �' ..�.... � ;: /' Application.Approved By . -l/ - ��.v . .� --- -------- ---- - ------- ... ... - ' LYare Application Disapproved for the following reasons- -------------------------------------------...---................------------...........-----.......----------.-------------.._- - ............................................................................... ..----------------------- ''�...,..rr��• cam Permit No. - ..... - ..-....... Issued -- ---- �,�• JAJ THE COMMONWEALTH OF MASSACHUSET, S . . _ BOARD,OF HEA`LIT�H� TOWN-OF BARNSTAB�LEPi �xi ' ..C�P #itteaf attt>nce ti y .........................................................._ ,-.... .�...; �..g _. "al System coristructed ( �or Repaired ( ) THIS IS TO CERTIFY That the Individual Se a e DIs. os, b ------------------------------------------_.------ -------------------------------------- i"'�-" Installer at -------%.2 ----- -....---- f has been installed in accordance with the provisions of TITLE of The Sta Environmental Code as described in the application for Disposal Works Construction' dated Permit No. - _ _.. -.. .. .--..,�.... __. ..�' -- -. .. ... '� � . THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.... .......... `� ..I. .z—._..._----------------------- --------- Inspector ------------ J _ - THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE No.. ...2 :.... ff FEE. r_k� �,a���l�rt�n �ertttit Permission is hereby granted......... ✓_.w_.'1 .. ......................•------............................---- to Constru,�ct-�( )f or Repair ( ) at} Individual Sewage �osah System r at No.---- �' -' �� -04!- �=�-'----• r� �,�,��-•�,'�/�i'-----------------------------••---.-. - tr - Street as shown on the application for Disposal Works Construction Permit .. .......................................................... Board of Health DATE----_------ - �' ' 0 `' ---------------------------------- v FORM 36508 HOBBS 6 WARREN.INC..PUBLISHERS vmri, ENVIROTECH LABORATORIES, INC. MA Cert. No.: M-MA 063 �7 449 Rte. 130 • Sandwich,MA 02563 (508)888-6460 • 1-800-339-6460 FAX(508)888-6446 CLIENT: Ted Hitchcock LOCATION: Lot 2 Lisa Lane ADDRESS: P.O. Box 654 W. Barnstable, M Hyannisport, MA 02649 SAMPLE DATE: 8-11-95 COLLECTED BY: D. Pennini/Scannell Well DATE RECEIVED: 8-11-95 TIME: 1:OOPM LAB I.D. #: E8-260 JOB TYPE: New well SAMPLE I.D. DAS 2 WELL SPECS.: 94' RESULTS OF ANALYSIS: Parameters Units Recommended Result Limit Coliform bacteria/100n1 (MF Method) 0 0 PH pH units 6.0-8.5 5.80 Conductance umhos/cm 500 142 Sodium mg/L 28.0 12.2 Nitrate-N mg/L 10.0 0.14 Iron mg/L 0.3 0.09 Manganese mg/L 0.05 0.012 Volatile Organics See report attached. EPA 601/602 ug/L None detected COMMENTS: Low pH indicates high corroisve characteristics. Yes No WATER IS SUITABLE FOR DRINKING PURPO FOR P TERS TESTED,.. X1CX � Date o ar LT = Less Than Laboratory irector 8-17-95 12:08 ;GROUNDWATER ANALYTICAL, + 508 759 4475;4 2/ 4 G/TOU x11 r rATE 1 ANALYTICAL EPA METHODS 601 and 602 Volatile Organics (GC/PiD/ELCD) Field ID: E8260 Lab ID: 11522-01 Project: Hitchcock/Lot 2 Lisa Batch ID: VG3-0431-M Client: Envirotech Sampled: 08-11-95 Cont/Prsv: 40mL VOA Vial/HCl Cool Received: 08-14-95 Matrix: Aqueous Analyzed: 08-16-95 PARAMETER CONCENTRATION REPORTING LIMIT (ug/L) (ug/L) Dichlorodifluoromethane BRL 5 Chloromethane BRL 5 Vinyl Chloride BRL 5 Bromomethane BRL 5 Chloroethane BRL 1 Trichlorofluoromethane BRL 1,1-Dichloroethene BRL I Methylene Chloride BRL 1 trans-1,2-Dichloroethene BRL I 1,1-Dichloroethane BRL 1 cts-1,2-Dichloroethene * BRL 1 Chloroform I 1,1,1-Trichloroethane BRL 1 Carbon Tetrachloride BRL Benzene BRL 1 14-Dichloroethane BRL 1 Trichloroethene BRL 1 1,2-Dichloroproppane BRL I Bromodichloromethane BRL I 2-Chloroethyyl Vinyl Ether BRL 5 cis-1,3-Dichloroprope.ne BRL I Toluene BRL I trans-1,3-Dichloropropene BRL 1 1,1,2-Trichloroethane BRL 1 Tetrachloroethene BRL Dibromochloromethane BRL 1 Chlorobenzene BRL 1 EthY lbenzene BRL 1 meta-and para-Xylene * BRL 1 BRL 1 ortho-Xylene Bromoform BRL 1 1,1,212-Tetrachloroethane BRL I 1,3-Dichlorobenzene BRL 1 1,4-Dichlorobenzene BRL 1 1,2-Dichlorobenzene BRL I QC SURROGATE COMPOUND SPIKED MEASURED RECOVERY QC LIMITS a,a,a-Trifluorotoluene 30 30 99 % 87 - 113 % 1,2-Dichloroethane-d4 30 27 89 % 83 - 117 % BRL = Below Reporting Limit. n Non-target compound. Method References: Method 601 - Purgeable Halocarbons and Method 602 - Purgeable Aromatics, 40 C.F.R. 136, Appendix A (1986). s� a� pj tiX• I_ P � `I )IMItlb i I I" e II ----------------- . ��--� �a4. `••.' � yet CD I(D s' 'f \ •'4 / / _\ XITCNCX o0 F 6 � a A � �`� ��• ';,'I+___ .. .. �Lam" ef ``\ `� nu ell \ w4 r-i! • .`� 6 ! ,�, rue wftiw��'�• f w s FIRST fLOOR PLAN ]�'l6�1� �F� ••'•, +' �9• �zoo.Scale� S74" = 3f-0^ d,�ld�� pFSoB S PMMilIG iYIC• First Floor Flan t SHMMIL�XtA .. /'{ 00 1� 7 ,�f i -P 9,xq use 8. infltrators with 4 ' of stone, -; sides and 14" of stone- for a base, and 3k6 stone at• ends. � r _ � Is fib" 14'' nI o "•r:' ', �•.` - , L e. C C - i _t1OF UA 04 I fi-- ��C � • - - -- �43 �r�b �'_� sr�+� 2. I S' - a , Calculations for. system Bot 11x55=605x0 74= 448 fiO 1 side 132x2x0.74 = , 195 y total ; 643 gpd -- 1 — �ir-�t7•.�L_. 4 -. may-- , -i--. \ r t ' Date 7-;21-95 40. lSLaiV_�ATL D S J • i - „ ---f--'t ; L4-+