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HomeMy WebLinkAbout0121 LOMBARD AVENUE - Health 121 LOMBARD AVE., W. BARNSTABLE_ A= i 16 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 121 Lombard Ave Property Address Kevin Sylver Owner Owner's Name r• � information is to required for every West Barnstable Ma 02668 10-21-15 r, 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. Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms �I # �' Z L•C) on the computer, use only the tab 1. Inspector: key to move your cursor-do not Matthew F. Gilfoy use the return Name of Inspector key. B&B Excavation Company Name 14 Teaberry Lane �I Company Address Sandwich Ma. 02644 City/Town State Zip Code (508)477-0653 S113640 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 10-21-15 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. h0 MU VIS t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 121 Lombard Ave Property Address Kevin Sylver Owner Owner's Name information is required for every West Barnstable Ma 02668 10-21-15 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 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. 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): l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 121 Lombard Ave Property Address Kevin Sylver Owner Owner's Name information is required for every West Barnstable Ma 02668 10-21-15 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments G1 121 Lombard Ave Property Address Kevin Sylver Owner Owner's Name information is required for every West Barnstable Ma 02668 10-21-15 page. City/Town 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"". P PP Y 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 1/z 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 121 Lombard Ave Property Address h Kevin Sylver Owner Owner's Name information is required for every West Barnstable Ma 02668 10-21-15 page. Cityfrown 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. ❑ 0 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 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 121 Lombard Ave Property Address Kevin Sylver Owner Owner's Name information is required for every West Barnstable Ma 02668 10-21-15 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A ® ❑ Was the facilityor dwelling inspected for signs of sewage back u ? 9 p 9 9 P ® ❑ 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? El ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems. The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts - Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 121 Lombard Ave Property Address Kevin Sylver Owner Owner's Name information is required for every West Barnstable Ma 02668 10-21-15 page. Cityfrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 4 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d see below 9 ( Y 9 (gP ))� Detail: **well water** Sump pump? ❑ Yes ® No Last date of occupancy: current 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts a . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 121 Lombard Ave Property Address Kevin Sylver Owner Owner's Name € information is required for every West Barnstable Ma 02668 10-21-15 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: owner-last pumped 1 1/2 years ago Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 121 Lombard Ave Property Address Kevin Sylver Owner Owner's Name information is required for every West Barnstable Ma 02668 10-21-15 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: 1996 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2feet 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(IIocate on site plan): 4'6" Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 gallon Sludge depth: 6" t5ins•3113 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 II 121 Lombard Ave Property Address Kevin Sylver Owner Owner's Name information is required for every West Barnstable Ma 02668 10-21-15 f page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 30" Scum thickness 3" 6" Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 14" How were dimensions determined? measured Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): At time of inspection septic tank appeared to be in working order with liquid level equal with outlet invert. Tank is in need of pumping at this time. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts - Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 121 Lombard Ave Property Address Kevin Sylver Owner Owner's Name information is required for every West Barnstable Ma 02668 10-21-15 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.): I 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.): 4 *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts . Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M , 121 Lombard Ave Property Address Kevin Sylver Owner Owner's Name information is required for every West Barnstable Ma 02668 10-21-15 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): At time of inspection D-box is in working order with no sign of back up or carry over. 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 . Title 5 official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 121 Lombard Ave Property Address Kevin Sylver Owner Owner's Name information is required for every West Barnstable Ma 02668 10-21-15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 3 500gallon ❑ 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 soils, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): At time of inspection leaching appears to be in working order with no sign of hydraulic failure. 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-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts - Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 121 Lombard Ave Property Address Kevin Sylver Owner Owner's Name information is required for every West Barnstable Ma 02668 10-21-15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: 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 Groan Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 121 Lombard Ave Property Address Kevin Sylver Owner Owner's Name information is required for every West Barnstable Ma 02668 10-21-15 page. City/Town 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 Fron 51 W° if b O O O l5ins•3/13 Title 5 Official Inspection Form: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 121 Lombard Ave Property Address Kevin Sylver Owner Owner's Name information is required for every West Barnstable Ma 02668 10-21-15 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: No Gw 156" 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: 2-27-1996Date ❑ Observed site (abuttingproperty/observation hole within 150 feet of SAS) ) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Plan on file with BOH Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 121 Lombard Ave Property Address Kevin Sylver Owner Owner's Name information is required for every West Barnstable Ma 02668 10-21-15 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist E Inspection Summary: A, B, C, D, or E checked E Inspection Summary D (System Failure Criteria Applicable to All Systems) completed E System Information— Estimated depth to high groundwater E Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 TOWN OF BARNSTABLE LOCATION J,L[ _La M b o rJ Ave._ S n VILLAGE ASSESSOR'S MAP&PARCEL ==V1;t-PWS NAME&PHONE NO. COAA&kl L -1-n SEPTIC TANK CAPACITY k500 ,�cj LEACHING FACILITY. (type) 0,1�¢,-v^bA4,-,:z (size) SCE NO.OF BEDROOMS j OWNER ' ,1k� PERMIT DATE: C6#hvt"M' DAT 5P 3 G Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY QIVVb I J /'J•f / J / ! r a r f f f f'f•f f f J J f f J f f I f f f f f f ' f f f f f f ! ♦ftJ♦/♦J\f♦f♦f\/\J4f`/\l J f f f J J\f\/\f\I\ `/\f\f\f4f\f\f♦J\f\!\ 51 \J\F\/♦f♦/\f\/\f\f\f\f\f f♦f\ J /\ f\I\f\f\f\ \f\f��� f\f\f\ k , \ , , \ \ ♦ \ \ \ , , , 4 , , , ,., , , ♦ , , , , , , f f J f f f , , , , , , , , , , \ ♦ \ \ \ \ , 29 28 2 . ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 121 Lombard Ave. Property Address Michael O'Neil — Owner Owner's Name information is West Barnstable MA 02668 August 3, 2010 _ required for 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. Please see completeness checklist at the end of the form. Important: A. General Information When filling out forms on the computer,use 1. Inspector: only the tab key ' to move your Patrick M. O'Connell cursor-do not Name of Inspectcr LL use the return key. Septic Inspection Services Co. Company Name 189 Cammett Road Company Address c --I Marstons Mllls MA 0264= O ; City/Town State Zip Cow 508.428.1779 S112855 Telephone Number License Number B. Certification I certifythat I have personally inspected the sewage disposal system at this address and tl�a the; information reported below is true, accurate and complete as of the time of the inspection.--Ue it ss ection ; 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 (--2� , A August 3 2010 Job# 10-198 In ector'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. l5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 Commonwealth of Massachusetts 19Title 5 Official Inspection 0=orm Subsurface Sewage Disposal System Form -Not for Voluntary Assessments . 121 Lombard Ave. Property Address Michael O'Neil Owner Owner's Name information is required for West Barnstable MA 02668 August 3, 2010 every page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: Tank is not in need of pumping at this time leaching chambers had 2-3"of standing water. _ i B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old'or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments r 121 Lombard Ave. _ Property Address Michael O'Neil Owner Owner's Name information is required for West Barnstable MA 02668 August 3 2010 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 117 i Commonwealth of Massachusetts 4 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 121 Lombard Ave. Property Address Michael O'Neil Owner Owner's Name information is required for West Barnstable MA 02668 August 3, 2010 every page. Citylrown 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 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 t5ins•09/08 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 121 Lombard Ave. Property Address Michael O'Neil Owner Owner's Name information is g required for West Barnstable MA 02668 August 3 2010 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins-09M Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 ofA7 �• Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 121 Lombard Ave. Property Address Michael O'Neil Owner Owner's Name information is g required for West Barnstable MA 02668 August 3, 2010 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 systemsp The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of'17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments '< 121 Lombard Ave. Property Address Michael O'Neil Owner Owner's Name information is g required for West Barnstable MA 02668 August 3, 2010 every page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 3 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 years usage d N/A Well Water Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Currently Occupied. 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-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of,17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments lug 121 Lombard Ave. Property Address Michael O'Neil Owner Owner's Name information is 9 required for West Barnstable MA 02668 August 3 2010 every 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: Tank pumped 2-3 months ago. Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of'17 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 121 Lombard Ave. Property Address Michael O'Neil Owner Owner's Name information is August 3, 2010 West Barnstable MA 02668 Au required for 9 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1995 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2'feet Material of construction: ❑cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 4' feet Material of construction: ®concrete ❑ metal 0 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 ❑ Noi. Dimensions: 10.5' long x 5.8'wide- 1500 gal. Oil Sludge depth: t5ins•09/08 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 121 Lombard Ave. Property Address Michael O'Neil Owner Owner's Name information is West Barnstable MA 02668 August 3 2010 required for 9 every page. Citylrown 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 0" 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? Measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank had liquid only, no solids. Liquid level was found at bottom of outlet invert and tees were intact and clear. 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-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 o017 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 121 Lombard Ave. Property Address Michael O'Neil Owner Owner's Name information is g required for West Barnstable MA 02668 August 3 2010 every page. Cityfrown 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments y 121 Lombard Ave. Property Address Michael O'Neil Owner Owner's Name information is g required for West Barnstable MA 02668 August 3, 2010 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): No solids or high stains. 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.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of,17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 121 Lombard Ave. Property Address Michael O'Neil Owner Owner's Name information is g required for West Barnstable MA 02668 August 3, 2010 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Type. ❑ leaching pits number: ® leaching chambers number: Three 500 gal chambers. ❑ 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.): Observed 2-3"of standing water with a high stain line 1"above current level. 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 121 Lombard Ave. Property Address Michael O'Neil Owner Owner's Name information is g required for West Barnstable MA 02668 August 3, 2010 every page. City/rown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation„ etc.): t5ins•09/08 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 %1twozi 121 Lombard Ave. Property Address Michael O'Neil Owner Owner's Name information is West Barnstable MA 02668 August 3, 2010 required for — every page. City/town 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 / r•r'J / J / / r / / I 51 \ \ \ \ \ ♦ Y ♦ \ \ \I /♦I/\/\f♦/\/YJ\J\rYJ♦J\J\/\/` \/\%\J\JY/ /\I /\/Yf\ 29 28 2 MIT" Lombard A ve. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 121 Lombard Ave. Property Address Michael O'Neil Owner Owner's Name information is West Barnstable MA 02668 August 3 2010 required for g , 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 high ground water: 20 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: USGS topo map and town GIS. You must describe how you established the!figh ground water elevation: Town groundwater contour map shows water at el.15 and topo map shows property at el.40. Before filing this Inspection Report, please see Report Completeness Checklist on next page. l5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 121 Lombard Ave. Property Address Michael O'Neil Owner Owner's Name information is West Barnstable MA 02668 August 3 2010 required for 9 every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL,PROTECTION V , TITLE 5 - FC 1 �� OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS 3 , SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM �Q�1, "000 PART A CERTIFICATION ;.4 Property Address: lal s Owner's Name: Owner's Address. /1j1 ) reQ 2 Date of Inspection: Name of Inspec or- (please rint) �1 � P© � Company Nam n y ��� • Mailing Address- •®• a Telephone Number: _ CERTIFICATION STATEMENT 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 ir_the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to ection 15.340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes ee F urt r Evaluation by the Local Approving Authority ail Inspector's Signature:" Rate: X G � f --- :: 1.1. -- 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. Notes and Comments ****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. Title 5 Inspection Form 6/15/2000 page I Page 2 of]I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Ab,21 A Owner: Date of.Inspection: 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,3;10..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 thatthe 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 pipes)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval.of Board of Health)- -broken PP ) broken s pipe( )are replaced obstruction is removed 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 ass inspection if with ap proval of the P P ( Board of Health PP broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address uu cad , a 7 Owner: Date of Inspection:zaZL5-11 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. with 310.CMR 15.303 1 b that the nce ( )( ) ' accordance .. ass unless Board of.Health determines m 1. System will p -- system is not functioning in:a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water — Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: The.system:has a septic tank and soil;absorption system(SAS)and.the`SAS is within 100 feet of a su_rface 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 coliform bacteria and volatile organic compounds indicates.that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than.5 ppni,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of l 1 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: /mil s Owner: Date of Inspection: D. System Failure Criteria applicable to all systems:. You must indicate"yes"or"no"to each of the following for all inspections: Yes N _ 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 V 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''/s.day flow Required pumping more than 4 times'in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped V! 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 l 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 coliform bacteria and volatile organic compounds .indicates that the well is free from pollution from that facility 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.) (Yes/No)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,'0Wgpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) 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. 4 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: a Owner: Date of Inspection: 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) &I" Was the facility or dwelling inspected for signs of sewage back up? v "- 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? _V_ 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:. . Yes no 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(3)(b)] 5 Page 6 of I 1 OFFICIAL INSPECTION FORM-NOT FOR:VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM .PART C SYSTEM INFORMATION Property Address: Owner: Date of Inspection: 157 Q FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number'of bedrooms(actual):L.3 DESIGN flow based on 310 CMR 15.203.(for example: 1.10 gpd x#of bedrooms):Z? Number of current residents: Does residence have a garbage'grinder(yes or no): 124' Is laundry on a separate sewage system(yes or no);/ qif yes separate-inspection required] - Laundry system inspected(yes,or no): eQ60-- Seasonal use:(yes or no): Water meter readings,if available(last 2 years usage(gpd)): Sump pump(yes or no): Last date of occupancy:n h.-— COMMERCIAL/INDUSTRIAL/��- Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap.present(yes or no):_ Industrial waste holding tank present(yes or no):— Non-sanitary waste discharged to the Title 5 system(yes or no):_ Water meter readings,if available: Last date of occupancy/use: OTHER(describe)- GENERAL INFORMATION Pumping Records J/ Source of information: w_' �®l'` Was system pumped as pah of the inspection(yes or no : �-- If yes,volume pumped: gallons--How was quantity,pumped determined? Reason for pumping: _ y TYPEDF 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): proximate age of all components,date installed(if known)and source of information: Were sewage odors detected when arriving at the site(yes or no 6 Page 7 of 11 OFFICIAL INSPECTION FORM—NOT. FOR VOLUNTARY ASSESSMENTS SUBSURFACESEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1.2J Owner: Date of Inspection: BUILDING SEWER(locate on site plan),,�� Depth below grade: Materials of construction:_cast iron _40 PVC_other(explain): Distance from private water supply well or suction line:' Comments(on condition ofjoints,venting;evidence of;leakage,etc.): SEPTIC TANK: d/ (locate on site plan) Depth below grade: ,/ �d � oa Material of construction:_concrete_metal—fiberglass.___polyethylene _other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) _ r / Dimensions: Sludge depth: q 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: 71 Distance from bottom of scum to bottom of outlet tee or baffle: T How were dimensions determined: JO_P ai akp/pU Comments(on pumping recommendations, '`let and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet inve evidence of.leakage, etc.)• O asG GREASE TRAP• ocate on site plan) 7 Depth below grade:_ 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: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.):. 7 Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: d 44 "A Owner: Date of Inspection: 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/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: y (if present must be opened)(locate on site plan) . Depth of liquid level above outlet invert: ,Ztutlets'equali .��Comments(note if box is level and distribution to ' any evidence of solids carryover, any evidence of :.leal�a�e into or out of box,'etc . JJ �� hL 42 PUMP CHAMBEV—X Ocate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): 8 ;Page 9 of I l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM,INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: l "A t / Owner: Date of Inspection: / �i�C SOIL ABSORPTION SYSTEM(SAS): J,,::�Tlocate on site plan,excavation not required) located explain why: If SAS not p �' Type _ leaching pits,number: -- 1,!!�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,a etc.): CESSPOOL%`� '�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 or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY/Yj,( 1'Tcate 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.): 9 Page 10 of I I OFFICIAL INSPECTION P`.ORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: / Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within.100 feet.Locate where public water supply enters the building. e 1 lip 10 Page I 1 of 11 OFFICIAL INSPECTION FORM—NOT FOR.VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: Date of Inspection: /Q.�a&-(2 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: 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: OC!- 11 B/A.RNSTABLE L OCATION SEWAGE # 0 «LLAGE eAJ'e-0F1` 67cr/11JIC01rIK ASSESSOR'S MAP & LOT c 4 ndn INSTALLER'S NAME&PHONE NO. /e !�G .��� 7 7 C OGC� SEPTIC TANK CAPACITY / J-C9 Q \ 155 —035 O DZ 4ea �LEACHING FACILITY: (type) C3)S��G. =AF CZr (size) NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: -7-Z rl/ Z' COMPLIANCE DATE: _ Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility �r�CBv�l41W 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 e ' t within 300 feet of 1 aching facility) / Feet Furnished by ��% �� I. i 1.o fIr 2. PAO, .._. r tit � t � AMORS No. PARCELN(e ���.®4_ - Fee/ vL�62� THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 0(ppYicatiou for Migogai *pe;temc Cou5tructiou Permit Application is hereby made for a Permit to Construct( )or Repair( )an On-site Sewage Disposal System at: Location Addrgss o of No Owner's Name,Ad�ess and Tel No. / Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.j o. Type of Building: Dwelling No.of Bedrooms Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures /f /J Design Flow �� `,0 �/l�gallons per day. Calculated daily flow 7 c gallons. Plan Date�f�/ `_yr, Number of sheets Revision Date Titlq S. -1t ,/` S-e � Description of Soil !4& ki<6C1O A rr � 7a r ";;'c— cJ 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 t nvironmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by thjsjWird of Hea Signed Date .01 Application Approved by Application Disapproved for the following reasons Permit No. / fJ J_11� Date Issued *'' Zu \�/, 4. Free 1 No. THE eCOMMONWEALTHOF MASSACHUSETTS PUBLIC HEALTH DIVISION-TOWN OF BARNSTABLE., MASSACHU.SETTS - 01pprtcatton for Mt5pozar *pgtem �Congtructton Permit .. i Application is hereby made for a Permit to Construct( )or Repair( )an On-site Sewage Disposal System at: Location or Lot No Ow ss Add ner's Name,Ad ss and Tel.No.' �� ' ��•� • it6 sb � i �a ✓H, 7G aZ Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel. o. -7 G 2 f Type of Building: Dwelling No.of Bedrooms Garbage Grinder( ) 'Other Type of Building No. of Persons Showers( ) Cafeteria( ). Other Fixtures /� ,,.� Design Flow � -0 /�OJ gene /gallons per day. Calculated daily flow ® gallons. Plan Date -Z / Ir Z? / .76 Number of sheets Revision Date Title S. ;2!!!51 /J/1-Xc1lGI 1-7ZA27G. e-.- Description of Soil "" a r1<6 L 4/J A O'rs-r ` 362 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 oft Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Ed of Health. Signed Date Application Approved by f Application Disapproved for the following reasons' Permit No. �+ '"/ Date Issued THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Certificate of Compliance / TH S IS TO CERTIFY,that the On-site Sewage Disposal System installed(Vor repaired/replaced( )on O AF f. by � � . t_k�_ for e, G "( as r! has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. ". dated OWoo � Use of this system is conditioned on compliance with the provisions set forth below: No. +* Fee,z// i N P THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS to on! tru e�tg�o�ar �p� to � coon Permit Permission is hereby granted to t _C -, to construct O repair( )an On-site Sewage System located at , and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions: All construction must be completed within two years of the date below. Date: r t� Approved by,. J ENVIROTECH LABORATORIES, INC. MA Cert. No.: M-MA 063 449 Rte. 130 • Sandwich, MA 02563 (508)888-6460 • 1-800-339-6460 FAX(508)888-6446 CLIENT: Nickulas Building Co. LOCATION: Lot 2 ADDRESS: 270 Communications Way Lombard Ave. W. Barnstable, MA 02601 W. Barnstable, MA SAMPLE DATE: 3-17-96 COLLECTED BY: T. Desmond/ Desmond Wells DATE RECEIVED: 3-18-96 TIME: 3:30PM LAB I.D. #: E3-185 JOB TYPE: New Well SAMPLE I.D. #: E3-185 WELL SPECS. : 771/27, RESULTS OF ANALYSIS: Parameters Units Recommended Limit Result Coliform bacteria/100ml (MF Method) 0 0 pH pH units 6.0-8.5 6.55 Conductance umhos/cm 500 157 Sodium mg/L 28.0 12.0 Nitrate-N mg/L 10.0 0.01 Iron mg/L 0.3 0.33 Manganese mg/L 0.05 0.051 Volatile Organics See attached report. EPA # 601/602 ug/L 10,000 1 ortho-Xylene COMMENTS: Iron and Manganese are not a health hazard. Yes WATER IS SUITABLE FOR DRINKING PURPOSES FOR P TERS TESTED. XXX Date 3 2cl§ on ld J. Saattr Laboratory DiVeptor LT = Less Than GROUNDWATER ANALYTICAL EPA METHODS 601 and 602 Volatile Organics (GC/PID/ELCD) Field ID: E3185 Lab ID: 12938-01 `' Project: Nickulas Lot 2 Lombard Batch ID: VG3-0530-W Pro3 /Client: Envirotech. Sampled: 03-1896Received: 03-19-96 a HC1 Cool OA Vi 1 Cottix: Aqueous V / Analyzed: 03-20-96 Matrix: Aqueous PARAMETER CONCENTRATION REPORTING LIMIT (ug/L) (u9/L) Dichlorodifluoromethane BRL 5 Chloromethane BRL 5 Vinyl Chloride BRL 5 Bromomethane BRL 5 Chloroethane BRL 5 Trichlorofl.uoromethane BRL 1 1,1-Dichloroethene BRL 1 BRL I Methylene Chloride BRL 1 trans-1,2-Dichloroethene BRL 1,1-Dichloroethane 1 cis-1,2-Dichloroethene * BRL 1 BRL 1 Chloroform BRL I 1,1,1-Trichloroethane BRL 1 Carbon Tetrachloride BRL I Benzene BRL 1 1,2-Dichloroethane BRL I Trichloroethene I 1,2-Dichloropropane BRL Bromodichloromethane BRL 5 2-ChloroethyyI Vinyl Ether BRL cis=1,3-Dichloropropene BRL I Toluene BRL I trans-1,3-Dichloropropene BRL I 112-Trichloroethane BRL , , 1 Tetrachloroethene BRL 1 Dibromo chloromethane BRL 1 Chlorobenzene BRL 1 BRL Ethylbenzene 1 meta-and Para-Xylene * BRL 1 ortho-Xylene * 1 Bromoform BRL I 1,1,2,2-Tetrachloroethane BRL 1 1,3-Dichlorobenzene BRL I 1,4-Dichlorobenzene BRL I 1,2-Dichlorobenzene BRL I QC SURROGATE COMPOUND SPIKED MEASURED RECOVERY QC LIMITS a,a,a-Trifluorotoluene 30 30 100 % 87 - 113 % 1,2-Dichloroethane-d4 30 28 94 % 83 - 117 % BRL = Below Reporting Limit. * Non-target compound. Method References: Method 601 - Purgeable Halocarbons and Method 602 - Purgeable Aromatics, 40 C.F.R. 136, Appendix A (1986). BOARD OF HEALTH TOWN OF BARNSTABLE )PeCC Congtruct ion Permit Permission is hereby granted---- L✓ ------ -------------------------------------------------------------------------------------- to Construct K), Alter ( ), or r Repair ( aan Indyv_idual Well at --- -- ------------- street as shown on the application for a Well Construction Permit No. ---------------------------- —--------------- Dated------—------------------------------------------------------------------------------- Board of Health DATE---- -- -- --------------------------— ro No.---�----�-`-- � � Fee--A-.--------- BOARD OF HEALTH TOWN OF BARNSTABLE ApplicationArlVell Con0ructionPermit Application is hereby made for a permit to',construct ( ), Alt e ( ), or Repair K)an individual Well at: Location — ddress / Assessors Map and Parcel ---------------------------------C �-------- Owner Address --r--- ---- 1-/-e�-------------------------- - - ----------------------------------------------------------------------------------------------------- Installer — Driller / Address Type of Building Dwelling------------- �' /.y -----.. ------ Other - Type of Building--------------------------------- No. of Persons----------------------------------------------------- `! Typeof Well------------%------------------------ -- Capacity ----------------------— ----- Purposeof Well---------------------------------------------------------------- Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation — The undersigned further agrees not to place the well in operation until a Certific .of Co ance has been issued by the Board of Health. -- Signed -- 1�Li� --- -- --- -------- ------- -------�--d------- � G Application Approved By- - , -- date Application Disapproved for the following reasons:------—------------------------—------------------------------------------------------- --------------------------------------- --------------------------------------------------------------------------------------------------- date PermitNo. ------------ -- -- --------------------- Issued------------------------------------------------------------------------------ date BOARD OF HEALTH TOWN OF BARNSTABLE (Certificate ®f (Compliance THIS IS TO CERTIFY, That the Individual Well Constructed ( -(�, Altered ( ), or Repaired ( ) bY----------L— - -- &J-1i(Q------------—------------------------------------------------------------------------------------------------------------ Installer at- --�—_Q �Z —� �------ ems "--l �_ --------------------------------- 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)A`j(O-11== ---Dated----�,�+ 6/ t6 THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE- --- —- — -- =-------—----- — - Inspector---------------------------------------------------------------------------- BOARD OF HEALTH TOWN OF BARNSTABLE Yell Con5truct ion Permit No Fee ��-——---------- Permission is hereby granted ------ —------------------------------------------------------------------------------------ to Construct, Alter R an InWd' *dual Well at- "Z No -------------------------------------------- Street as shown on the application for a Well Construction Permit No. —------------------------ Dated------------------------------------—---------------------------------------------NI ------------- —------------------------- Board of Health DATE —--------- —-------- No.--A�----�� Fee-------- -- BOARD OF HEALTH IC ' TOWN � O-P BARNSTABLE Application for Velr Con0ructioni3ermit Application is hereby made for a permit to Cbnstru&`( 0, Alt e ( ), or Repair ( )an individual Well at- ' — -------� Assessors- p and Parcel 4 / Location — ddress Assessors Map and Parcel /� ----------—------------------ - S ///!1 Ow ier Address — '`--- — ------------------------------------------------ ----------------------------------------------------------------------------------------------------- Installer — Driller / Address ?' Type of Building - /-------.��----- Dwelling-------------"- ---- Other - Type of Building--------------------------------- No. of Persons--- -- �7 --------------------------- Typeof Well— - — - ------------ --------------- Capacity ------------------------------------ Purposeof Well---------------------------------------------------------------- Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town"of Barnstable Board of Health Private Well Protection Regulation — The undersigned further agrees not to place the well in operation until a Certific1pe of Compl' nce has been issued by the Board of Health. /S i Signed Application Approved By -- — — - - --------- —- -— ------- date Application Disapproved for the following reasons:------—------------------—--------------------------------------------- ------------------------------------ -------------------------------------------------------------- date PermitNo. -- —r------ - ------------------------------ Issued----------------------------------------------------------------------------- date uaa+�...��.�.�.,u�.w.a. c.�.�.;�+rr,aw:-Y....-,.r�:.fa.+.�....r..+.,.+:u.k.a.�r.�w..n+.�s+�r-.�..i.:�rea.«q..x»w.�+....w.4..re,r�..rw...r...,rrr:�w.■..+.ir,ayas�.�..»„�.:...._:.._- .,..._�,.., ..,._.,.,....�_•:trxa.r:+r�+eaf!�� BOARD OF HEALTH TOWN OF BARNSTABLE Certificate ®f Compliance THIS IS TO CERTIFY, That the Individual Well Constructed ( X), Altered ( ), or Repaired by----------L-(-AIVJ", w!t u------------------------------------ --------------- - ----------------------------------------------------------------------------------------- ----- Installer at------�---�i--� �.�2 � �= --- e,J_ --,. /``"'""' - ------------------- -- 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 k)5JbJ--Z ------Dated-----`--2�. � �b THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE- --- ———-— ----- --- -- Inspector----------------------------------------------—- --— f ; ,i �c//Ch'/•vG vvEL C �X/ST ���� L EfICh�/.✓G ���� \ j8 • ,piST � �1 c �'ZS��-'v` ,c 1 \ 'P T 71 2 5p f i Q LOT A,/ , Z o F IC ti 7ZZ N \ / 0 Mi170" SCf1LE-'/,•= 2GD0 " f 4-0 T z �''�y S`sfOh//�✓L; T.� P�'DPD.SED T.'/i�'EE I ,B�p. 1 d!c/ELL/NG 5--W-76;E SYSTE/"7 PATH OF Mqs GOT NO. Z LOMC3A/�Q �l//ENUE J wo N �qy l-✓, .c3Ai4N=TAB[ E N1.9 G P 7, c� DOYLE,111 N N o.33589 9FG/STVR qN� S U. .c;V-IAIvzl 7;1/1 /1.9. O2,57-1 1 /ST f .=X/✓T _1 O �d66- Dc -77 � (7 P• � \ 4 � SEAT/c T t 03 �y f 7/ \ U/ 1 / EX/ST C 1 l� 1 �.ti ---� � I � l+rFLL ►, : ' , `D, � E �/.vim LOG�/S �1fi'.n .SC�GE• /"- 2GY0 ' I /o• �,,'' � \ \� � - , �� S/TE A/�/G SEI✓•�6 E �L Ate✓ `.. 40 FGR q•Z � 2 Apt" moo, l �•-� �HOh//Nc� T.�i� P.�'OPD.SED Ti5/.eEz'c � ,B�p,@aGN�.Z�WELL//V6�SEI•✓AG E SYSTEM ��P�ZH OF Mqs�� LOT IVO, 2 LDM,6-4170 ,gvEiVUE \ JOHN G /✓ ,B�Ri✓=TA�3G E MA, \ � P. SCALE / =SQ / �3 Eve?.E'Y Z 7 DOYLE,III v No.33589 /STER�� � ✓�i/it/ � 04YG E P.L. �: . �1 t r .. n S tJL s�w%9� sr T tsor� ,e � r _T -T 2 5 a � O Oh► Gd0 L � ''y [ h!6�IlD,b M A t MAX 9 � 8 � Sv P .. M ,D.CST dX 9 G MAX. /d �o AX N c . , 8 MA L oq�ty .. /,D 2 cDv� s :/'EA TONE � ' AN 5 4 /NY. a _y _ D P L CN D : DYR G Y L,. �f-3,s" 3 scf/ 4-o PYC. SEWER P/PE � Q• n. �.. .q 6__ � � , �", ; , •r.,,. r.srt N a d o Y ' � 43 G o D v MIX`� / !/ . :�3,g3 oa � � caor� c a , 38 e -1 _ �ti � s .•. .:.�.. o SO G Lam'• LE �, � STowE Ton�E , __A�^ 6... 0. 3 . 6 BE� Or 27 p 2 � � T N i s anrE Ti�iV�' Gt//T!� /50 C H Y � SAND 59Nd Dot/ D 5T E D NL ET D�/TLE T T OYR86 /O �t' 8 G / y d� 1 T/TLE aF ST �TToM T�' 3 EGT 3,, G ES/G ✓ G GCUL T O/VS GAaurkt?waa,er� NaT ENCOU/✓TE.E'E1a • _ 3 Z �>N /wch! ec�s� I sous. G A .c' BEd M X 1�D�/l 30 l> PI F�oN/ qT /o o y P� POD 3 3 � �sT >�i-oc'i�ED :O�/ `AUG. / , /995 . Bo�9.GD 4F � T P ,mod B R _ , WA,SHf STDNE . . Z 7 ' Y D. G S� D.9 6 S ,` L E�4G�/rVG';/r'� ///h'Eb. . A 330 6�,D 74 � � Y �-� � q . , , . qT v�s ..J ,sue�qq X p / q /��� -P USE. 3 ACf�'E /'.eECt1sT 500 G BE /4 EF1� � [T D p * Z3 6 G TY/' 0 S TTDM a /D X D - 3'a F / iO�J ao t Go �G sF T TOTAL O 4 '/N �S�l`�E, M - 4� � ,1 .pG�Ti�y 4 Y/G/y/ OF Gt�flC.�,�/iVG SYSTEM'! / _ �4G G� G. �f C ANC' /1/D GA�Pl3 USE /S � T T s - _. _ , k NOTE. CD�IPOrt�E.v�S SflAGG st/OT' BE c_'GW� 1✓ 4ZZ40 UNT/L Tf/� c /ry co; w E N ��/�� �DTff='YEl} ,�,� /'NSC'Es^7"/Dimes s1.vD As-BilitT`cE.P FrCATiGr✓ , . w 4 Z70 C f"9 N C T Y r ; HY S M .- EA GA A.� �: 9i2k/r✓ Y /CGE" fIN1! �9 i£�iAL TEG. . 3�2-�295 O //� s'�.dT C 7.4it/ F , D h' �w '` --- _ , f T l �- b 64 iJT _ 6 G7 B to -. 2 L IAq d o u 5 aces 1 1 n f , m 5� driE� 1 , d 1 0 t S i r 1ti�L G L 41:11141-*-111 E�Cyiw d :7 qz _ 1 o ► , 5�i N H OF f P 9s � s a GO p N c 4✓y . D -9YEi1/ o qS c.� DOYLE,1❑ -+ �, 27 No.33589 2 y 1 VNILLIAJW; 61 R , 6?/IPNIG 5G.9LG� / f=EET q STE p o LIE�ERNIAN y SU No' 23971 F D O Syy Et1 ONAI 174, ' i1/ E' L a c 9