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Home My WebLink About0056 LOTHROP'S LANE - Health 56 LOTHROP LN. ,W.BARNSTABLE A = 109 005 10 e 5 Commonwealth of Massachusetts Title 5 Official inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �F.l 56 Lothrop's lane 7t- Property Address r Koesel a: .y,9 Owner Owner's Name information is : required for every West Barnstable Ma 02668 8-7-17 ;; page. Citylrown 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 �j filling out forms R ss—o on the computer, use only the tab 1. Inspector: key to move your cursor-do not Chad Hathaway use the return key. Name of Inspector H.P.S. � Company Name P.O.Box 151 Company Address Forestdale Ma 02644 Citylrown State Zip Code 774-274-2581 12866 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 8/7/17 Inspector's Si ure Date The system inspector shall mit 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 n Pays Commonwealth of Massachusetts Title 5 official Inspection Dorm Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 56 Lothrop's lane Property Address Koesel Owner Owner's Name information is required for every West Barnstable Ma 02668 8-7-17 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: ® 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: septic functioning as designed 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 exfltration 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): L 3113 Title 5 Official Inspection Form: u � Subsurface Sewage Disposal System Page 2 of 17 Commonwealth of Massachusetts ha Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 56 Lothrop's lane Property Address Koesel Owner Owner's Name information is required for every West Barnstable Ma 02668 8-7-17 page. Citylrown 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 f Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments , 56 Lothrop's lane Property Address Koesel Owner Owner's Name information is required for every West Barnstable Ma 02668 8-7-17 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 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 %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 , 56 Lothrop's lane Property Address Koesel Owner Owner's Name information is required for every West Barnstable Ma 02668 8-7-17 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. [Phis 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 lnspecti®n Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 4M , 56 Lothrop's lane Property Address Koesel Owner Owner's Name information is required for every West Barnstable Ma 02668 8-7-17 page. Citylrown 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 Info rmation armatlon 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 t5ins•3113 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 , 56 Lothrop's lane Property Address Koesel Owner Owner's Name information is required for every West Barnstable Ma 02668 8-7-17 page. Citylrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 1 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 well 9 ( Y 9 (gPd))� Detail: well sample taken 8/7/17 tested at lab results are suitable drinking. results attached to report 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 56 Lothrop's lane Property Address Koesel Owner Owner's Name information is required for every West Barnstable Ma 02668 8-7-17 page. Cityfrown 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 Was system pumped as part of the inspection? ❑ Yes ❑ No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: pumped 2 months ago 06/17 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 Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments GM ,••�'L 56 Lothrop's lane Property Address Koesel Owner Owner's Name information is required for every West Barnstable Ma 02668 8-7-17 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: 2000 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1.75' feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: 40+ feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): ' Depth below grade: 1 feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) i If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 H 10 Sludge depth: less then 1" t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 56 Lothrop's lane Property Address Koesel Owner Owner's Name information is required for every West Barnstable Ma 02668 8-7-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 34" Scum thickness none 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? tape and sludge judge Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): pump every 2-3 years as maint. to protect leaching. tees in place no concrete decay or visable leaks 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 M , 56 Lothrop's lane Property Address Koesel Owner Owner's Name information is West Barnstable Ma 02668 8-7-17 required for every page. Cityrrown 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 reputed 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 Tile 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments °M 56 Lothrop's lane Property Address Koesel Owner Owner's Name information is required for every West Barnstable Ma 02668 8-7-17 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.): Dbox solid in good condition. no decay or rott. water level was at bottom of outlet no signs of being over full. 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: No inspection port located inspected through Dbox with sewer camera leaching was dry t5ins-3/13 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 M 56 Lothrop's lane Property Address Koesel Owner Owner's Name information is required for every West Barnstable Ma 02668 8-7-17 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 6 infultrators ❑ 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.): none 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 Title 5 Official Inspection Dorm Subsurface Sewage Disposal System Form-Not for Voluntary Assessments , 56 Lothrop's lane Property Address Koesel Owner Owner's Name information is required for every west Barnstable Ma 02668 8-7-17 page. CitylTown State Zip Code Date of Inspection D. System Information (coot.) 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 officinal Inspection Dorm Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Mr 56 Lothrop's lane Property Address Koesel Owner Owner's Name information is required for every West Barnstable Ma 02668 8-7-17 page. Cityrrown 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 f — 19 (0° _ 3 3- 73 3 - 3U O ,Sins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts Tile 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 56 Lothrop's lane Property Address Koesel Owner Owners Name information is west Barnstable Ma 02668 8-7-17 required for every page. Citylrown 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: 100+ 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: GIS town mapping lot where septic is el. 148 near by ponds el. 28 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 56 Lothrop's lane Property Address Koesel Owner Owner's Name information is required for every West Barnstable Ma 02668 8-7-17 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 t5ins•3113 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 ENVIROTECHLABO RAT ORIES,INC. MA CERT.NO.:M-MA 063 8 Jan Sebastian Drive Unit 12 Sandwich,MA 02563 (508)888--6460 1-800-339-6460 FAX(S08)888-6446 Client Name Hathaway Property Services Location 56 Lothrops Lane, Address PO Box 151 W Barnstable,MA Forestdale,MA 02644 Sample Date 08/07/17 Collected By Client Sample Time 12:15 Sample Type Well Date Received 08/07/17 Lab Order Number DW-172822 Well Specs a,. Analysis Requested Units Recommended Llmits Analysis Result Method Date Analyzed Analyzed By Total Coliform CFU/100m1 0 0 SM9222B 8/7/2017 IRS units 6.5-8.5 6.68 SM 4500-H-B 8/7/2017 LL Specific Conductancen umhos/cm 500 96 EPA 120.1 8/7/2017 LL Nitrite-N mg/L 1.00 <0.006 EPA 300.0 8l7/2017 LL Nitrate-N mg/L 10.0 0.95 EPA 300.0 8/7/2017 LL Sodium mg/L 20.0 8.8 EPA 200.7 8/9/2017 MC Total Iron mg/L 0.3 <0.01 EPA 200.7 8/9/2017 MC Manganese mg/L 0.05 <0.005 EPA 200.7 8/9/2017 MC Comments. Water meets EPA standards anp'flsujitalb3lefdrdrinking forparameters tested.Date 8/9/2017 Ronald J.S`aLaborato recor i I I I BRL=Below Reportable Limits *See Attached Page 1 of i rCertjfication is not available for this analyse for potable water samples.. CERTIFICATE OF ANALYSIS Page: 1 Barnstable County Health Laboratory Report Prepared For: Report Dated: 1/3/2007 �crro�. Leo Berard Buyer Brokers of Cape Cod Order No.: G0639173 128 Water Street Yarmouthport, MA 02675 Laboratory ID#: 0639173-01 Description: Water-Drinking Water Sample#: Sampling Location: 56 Lothrops Ln.West Barnstable,MA. Collected: 12/28/2006 Collected by: L.Berard Map 109 Parcel 005/010 Received: 12/28/2006 Routine ITEM RESULT UNITS RL MCL Method# Tested Nitrate as Nitrogen 0.54 mg/L 0.10 10 EPA 300.0 12/28/2006 Copper 0.74 mg/L 0.10 1.3 SM 3111B 1/3/2007 Iron BRL mg/L 0.10 0.3 SM 3111B 1/3/2007 Sodium 7.9 mg/L 1.0 20 SM 3111B 1/3/2007 Total Coliform Absent P/A 0 0 SM9223 12/28/2006 Conductance 77 umohs/cm 2.0 EPA 120.1 12/28/2006 pH 6.6 pH-units 0 EPA 150.1 12/28/2006 Water sample meets the recommended limits for drinking water of all the above tested parameters. Approved Byt(L ` irector) MCL=Maximum Contaminant Level RL = Reporting Limit Superior Court House, PO.Box 427, Barnstable, MA 02630 Ph: 508-375-6605 t " \ COMMONTWEAI;TH OF',MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFF AIRS ' . DEPARTMENT OF ENVIRONMENTAL PROTECTION �i TITLE 5 OFFICIr 1L INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM _PART A CERTIFICATION Property Address: � . xa � �2rd-1s4rC��Cr�� Owner's Name: AldalI .Owner's Address: �/ ( �g � ' •2.te Date of Inspection: r �r^��f,U • Name of Inspect (plea e pri3it) Company Nam . Mailing.Address: , d r�Q Telephone Number: '" CERTIFICATION STATEMENT v, -,j 1 certify that I have personally inspected the sewage disposal system at this address and that tF,6 information rep i2ed below is true, accurate and complete as of the time of the inspection. The inspection was.perR. ed baseEon myry training and experience in the proper function and maintenance of on site sewage disposal syste s. I arm DE.P approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The s stem: eaco V Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority F Inspector's Signature: —_ -- Date: _� /QL The system inspector shall submit:a copy of this inspection report to the Approving Authority(Doard'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.T'he original should be sent to the syste;n owner and copies sent to the buyer, if applicable, and the approving authority. Notes and Comments ****This report only"desr_rlbes.conditions at the time of inspection,and'under4he 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 671512000 page I ' } 1 Page 2 of l 1 OFFICIAL:INSPECTION'.FORMM— +NO T FOR VOLUNTARY• UNTARY ASSESSMENTS , S . `+ SUBSURFACE SENVAGE•DISPOS.AL SYSTEM I�ISPECTION FORM';` PART A CERTIFICATION (continued) Property Address: Owner:. Date of Inspection: /t Inspection Summary: Check' A,B,C,D or B./ALWAYS complete all of Section D A. Svstern Passes: JI have not found any information which.indicates that any of the failure criteria described in 310.CMR 15.303 or in 310 CMR 15.3.04 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 detenmined"please explain. The septic tank is metal and over 20 years old" or the septic tank (whether metal or not)is structurally unsound, exhibits substantial infiltration or exfiltration or,tank failure is imminent:System will pass inspection if the existing tank is replaced with a.complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. . ND explain: Observation of sewage backup or break out.or high.static water level in she distribution,box due-to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board.of Health): broken.pipe(s)are replaced obstruction is removed distribution,box is leveled or replaced ND explain: The system required pumping more thanA times a year due to broken or obstructed'pipe(s).The system will pass inspection if(with.approval of the.Board of Health): broken pipe(s) are replaced obstruction is removed I ' ND explain: Page 3 of l 1 OFFICIAL PiSPECTION FORM -.NOT FOR VOLUNTARY ASSESSMENTS. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTIONN'FORM PART:A CERTIFI CATION,(continued). Property Address: j�l .Owner."- Date od'I Pection: C. Fu Bevaluation_is Required rther. the Board.of Health: qred by l 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 ofEealth determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner wfiicli will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a'surface water — Cesspool or pr-vy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. Sys.tern 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 surface water supply or tributary to a surface water:supply. _ The system has aseptic 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 aseptic 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 deter-nine 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 ofamnzonia 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: 3. Page 4 of. 1 I QFFICIAI;.INSPEG.TION FORI'vl:- .NOT +{�R VO1LUI�d:I r"�R ':AS SESSMEN TS SUBSURFACE'SEW + .AGE DISPOSAL.SYSTEM INSPECTION:FORM PART.A. CERTIFICATION(continued) Property.Address: r. �. �— ala ` , Owner: Date of Inspection: � (y D. System Failure Criteria applicable to all systems: You must indicate"yes" or"no"to each_.of the following for alf inspections: s C, .. 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 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 %z day flow Required pumping more than 4 times in.the last year NOT due to clogged or obstructed pipe(s):Number of times pumped _ Any portion of the.SAS,.cesspool or privy is below high ground water elevation. Any.portion of cesspool or privy is..within 100 feet of a surface water supply or tributary, to a.surfac'e �J 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. 1/ Any portion of:a cesspool or-privy isdess than 100 feet but greater than.5.0 feetfrom 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 collform.bacteria and'v.olatile organic'coin pounds indicates that the.well.is free from pollution from'tliat..facilityand 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.] lV O (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'thc failure: E. Large.Systems: To be considered a large system the system must serve'a.facifity•with .a design flow.of 10,000 gpdd-to 1.5,000 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 1.5.304. The system owner should contact the appropriate regional office of the Department. Paoe 5 of 1.1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSLTR::F'ACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: ® ) 1as,e7 /oA -/� Owner: Mite of Inspection: Check if the following have been done.You must indicate"yes"or"no" as to each of the followine. 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) V. - _ Was the facility or-dwelling inspected for signs of sewage backup ? ' _ Was the site inspected for signs'of break out ? V Were all system components, excluding the SAS, located on site ? V _ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the;b'affles or tees, material of construction, dimensions, depth of liquid,.depth of sludge and.depth ofscum 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 CNIR 15.302(3)(b)] S Page 6 of 11. OFFICIAL INSPECTION`FORM,—NOT FOR VOLUN x;ARY:AS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECT ION FORM PART C SYSTEM INPORI''rIAI'IOi d Property Address.r Owner: ,� � / S � . j(.IA, Date,of Inspection: / �R (�• / FLOW CONDITIONS RESIDENTIAL V . . Number of bedrooms.(design):... Number of bedrooms (actual).: DESIGN flow based on 310 CMR 15.203 (for example: 11.0 gpd x# of bedrooms): Number of current residents:. Does residence have a garbage grinder(yes or no): �� _ Is laundry on.a separate sewage system (ye or no): ' [if yes separate inspection required] Laundry system inspected(yes or no): Seasonal use: (yes or no): 0 / Water meter readings, if avakable (last 2 years usage (gpd)): Sump.pump (yes or no): I;VVy is C Last date of occupancy: „�? at,Cy COMNIERCIAL/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 ti Source-of inforinat i013: ource ofinforrnation: 91 0 Was system pumped as part of the inspection (yes or no): Lt If yes,volume pumped: gallons --How was quantity pumped determined? Reason for pumping: TYPArOF 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 fxorri.system owner) _Ticht tank _Attach a copy'of the DEP approval _.Other(describe): Approximate age of all components, date installed(if known) and source of information: Were sewage odors.-detected when arriving at the site(yes or no):/ � Page 7 of l 1 OFFICIAL INSPECTION FORM —NOT FOR 'VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM JNFORMATION(continued) Property Address: ;(p XIA Owner. Date of Inspection: BUILDING SEWER (locate on site plan) IA/6 Depth below grade: .Materials of construction: cast iron _40 PVC other(explain): _ Distance from private water supply well,or suction line: Comments (on condition of Joints; venting, evidence of leakage, etc.): SEPTIC TANK: (Iocat:e on site plan) s Depth below grade: 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) Dimensions: Sludge depth:[) " Distance from top of sludge to bottom of outlet tee or baffle: --^ Scum thickness: Distance from top of scum t3 top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee.Qr baffle: . How were dimensions determined: Comments (on pumping rerommen tions, 'filet and outlet tee or baffle condition;structural integrity,liquid levels a elated to outlet invert, evidence of leakage, etc.): � r !GREASE TRAP: locate on site Jan / fir'f `.ILL( plan) 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 bottorn of sc-im 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, e:Adence of leakage, etc.): Page 8 of I OFFICIAL,INSPECTION FORM-NOT FORNOEUNTARY ASSESSMENTS. . . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSP:ECTIO' N FORM PART C SYSTEM INFORMATION(continued) Property Address:` AL Owners / Date of Inspection: a(�y TIGHT or HOLDING TANh�(� (tank must be pumped at time of inspectioii)(loc.ate.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•(con dition of alarm and float switches, etc.): DISTRIBUTION BOX: of present must.be opened)(locate on site.plan) Depth of liquid level above outlet invert.., Comments(note if box is level and distribution to outlqual, any evidence of solids carryover, any evidence.of .leakage into pr out 9f box,etc.): " PUMP CHAMBER:_ (locate 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.): Page 9 of l l OFFICIAL INSPECTION FORM.—NOT.FOR VOLUNTARY ASSESSMENTS SUDSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address-, LA_ 1 Me Owner: Date of lnspection . SOIL ABSORPTION SYSTEM, (SAS):___/'(locate on site plan; excavation not required) If SAS not located explain why: Type leaching.pits,number: l aching chambers, number: leaching.:galleries, number: leaching trenches, number, length: leaching fields,number, dimensions: •:overflow cesspool,number: _.innovative/altemative system. Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, l-eve] of ponding, damp soil, condition of vegetation, • tc. y R 1 f /� CESS-POOLS:JLV (cesspool must be pumped as part of inspection)(locate on site plan) Number and conf euration: Depff•-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:): 'PRI'VY g0(locate on site plan) Materials of constriction: Dimensions: Depth of solids: Comments (note condition ofsoil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.):. 4 9 i 5 Page 10 of 1.1 OFFICIAL INSPECTION FORM.-.NOT. FOR VOLvMARY ASSESSMENTS . SUBSURFACE SWAGE DISPOSAL ,SY,9TEM.INSPEC TIOM FORiYZ 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 t e,building. }IC7)n �J qC: lL � � a Page l I of]1 OFFICIALINSPECTION FORIM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURF'ACE SEWAGE DISPOSAL SYSTEM INSPECTION-FORiM PART C SYSTEM INFORMATION (continued) 'Property Address: —y Owner. Date of Inspection• SITE EXAM Slope Surface water Check cellar Shallow welts d Estimate .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 exzavators, installers—(attach documentation) ✓Accessed USGS database-explain: You must describe how you established the high groundwater elevation: 11 Permit Number: Date: Completed by: 6 1 HIGH GROUND-WATER LEVEL COMPUTATION Site Location: leee Lot No. Owner: &4. Zt-olloigo Address: Contractor: �f Address: �9 � _-Notes:.......----..____..._..... STEP 1 Measure depth to water table tonearest 1/10 ft. .............................................................................. .D'ate. month/day/year STEP 2 Using Water=i_evel' Range Zone and.Index_well-Map locate site and`determ,ine: IAp:Propriate index well..........:......................................... Water-level range zone ..................................................... STEP 3 .:. ..,....�-Using.,.,._._.....:.._,.._...__ monthly report "Current ..-Water:Resources Conditions" determine current depth to Water level for index well C........................... / month/year __.._......._........_.__._.... . __..._. _... STEP 4 UsingTable of Water-level Adjustments for index well (STEP 2A), current depth to water level for index well (STEP 3), - and water-le\,el zone (STEP 213) determine water-level adjustment .......................................................................................... STEP 5 Estimate depth to high water by subtracting the water- level`adjustm,ent(STEP 4) from measured depth to water level'at site (STEP 1) ............................................................................................................. Figure 13.—Reproducible computation form. 15 ' F*t R�trtTwaert�trft 1 ^ ' s 23-4 a TOWN )OF BARNSTABLE �6 C 10 LOCATION �S 101-�1"(1�;�// r SEWAGE # -lAg- VILLAGE � ' � �� C ASSESSOR'S MAP & LOT / bQCQ(0 INSTALLER'S NAME&PHONE NO. All-7 i7 7O SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) � 'C1d` NO. OF BEDROOMS y BUILDER OR OWNER PERMITDATE: ® COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist (1 on site or within 200 feet of leaching facility) Feet 6 Edge of Wetland and Leaching Facility (If any wetlands exist within 300 feet of leaching facility) Feet Furnished by I �3 73 TOWN OF BARNSTABLE LOCATION S b to SEWAGE #t-h�'f /✓a lea VILLAGE ' �d�� 3 � ASSESSOR'S MAP & LOT /Gz •�'fa INSTALLER'S NAME Sc PHONE NO. ,jr � SEPTIC TANK CAPACITY . . . (size),1��1 f�'/t?1`G�%� � LEACHING FACILITY: (type) NO.OF BEDROOMS BUILDER OR OWNER j lD COMPLIANCE DATE: ---- PERMITDATE: Separation Distance Between the: Feet Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Private Water Supply Well and Leaching Facility (If any wells exist Feet on site or within 200 feet of leaching facility) i Edge of Wetland and Leaching Facility(If any wetlands exist Feet within NO feet of leaching facility) Furnished by _ I I No. THE COMMONWEALTH OF MASSACHUSETTS } FEE r. BOARD OF HEALTH OF / "'✓ it�s 'i APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct Repair ( ) Upgrade ( ) Abandon ( ) - ❑Complete System ❑Individual Components is , !` L`fd' I w,-fwner',Name Map/Parcel# I dress s �Zv3��Gl[ lns aHer'r's Name esi er's Name 0 Address Address Telephone# Telepho # Type of Building: agawtz Lot Size d lP Sq.feet Dwelling—No.of Bedrooms Garbage Grinder ( ) Other—Type of Building No.of persons Showers ( ), Cafeteria ( ) Other fixtures Design Flow(min.required) gpd Calculated des i n flow U gpd Design flow provided 6 gpd Plan: Date c4AJ 1A VVNumber of sheets — Revision Date Title I Description of Soil(s) f Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation f G DESCRIPTION OF REPAIRS OR ALTERATIONS The undersi d agrees to in I the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and fu e a ees no to a the ys i operation until a Certificate of Compliance has been issue by the Board of Health. Signed Date Inspections 3 FORM t - APPLICATION FOR DSCP DEP APPROVED FORM 5/96 No. _s - 7 ' " IiE COMMONWEALTH OF MASSACHUSETTS:_ FEE BOARD OF HEALTH OF I � APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT r jl Application for a Permit to Construct (x) Repair ( ) Upgrade ( ) Abandon ( ) - ❑Complete/System ❑Individual Components Locatio wner's Name /a 9 5--�� P�• 64X i�0 /atii�r-� rA Lot I s aller's Name esi er's Name 6 721 —q„^` Address ddress /jfA,�irJ � Telephone# Telepho # Type of Building: ./ Lot Size A d l0 Sq.feet Dwelling—No.of Bedrooms Garbage Grinder ( ) i; Other—Type of Building. No.of persons Showers ( ), Cafeteria ( ) Other fixtures Design Flow(min.required) gpd Calculated design flow U gpd Design flow provided 4*6od Plan: Date e� ! Number of sheets Revision Date Z- Z Title e., Description of Soil(s)_ 1 . Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS 4� The undersigned agrees to in (I the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further)a ees no to ack the ys m i operation until a Ce'tificate'of Compliance has been issue by the Board of Health. Signed Date �6 ? .: . ., 3 Inspections ' FORM t - APPLICATION FOR DSCP DEP APPROVED FORM 5/96 No. 1 9v THE COMMONWEALTH OF MASSACHUSETTS FEE �G•+rl�t� O�BOARD OF HEALTH CERTIFICATE OF COMPLIANCE Description of Work: ❑ Individual Component(s) ercomplete System The undersigned hereby certify that the Sewage Disposal System;Constructed( ),Repaired( ),Upgraded( ),Abandoned( ) by: at .5610 V Al t y '_d. has been installed in accord Ace with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to-application No. dated Approved Design Flow (gpd) Installer t Designer: Inspector , a. Date The issuance of this certificate shall not be construed as c guarantee that the system will function as designed. FORM 3 - CERTIFICATE OF COMPLIANCE DEP APPROVED FORM 5/96 -__-. --_ --- -- -------- No. THE COMMONWEALTH OF MASSACHUSETTS FEE I T' 11 T- to BOARD OF HEALTH � v DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission Whereby granted to,.Construct (.,V Repair ( Upgrade ( ) Abandon ( ) an individual sewage disposal system aC (v as described in the application`�for Disposal System Construction Permit No. ? M dated 30 Zak Provided: Construction shall be completed within three years of the date of this permi�t,,All local con 'tions s�t/b�met. Date � Board of Healthr''��CX� t L , FORM 2 - DSCP DEP APPROVED FORM 5/96 FORM 1255 (REV 5/96) H&W HOBBS&WARREN TM PUBLISHERS- BOSTON J O SEP-01-99 03 :33 PM P. 16 II Dc? aru„e,lt of El+vironmeNtMl M110190rr+Mt,rDlvlsIon of Well, Resources ! WELL COMPLETION REPORT q WELL L CATtON Address o GEOGnArHic DESMPTION - � S E W of City/Town rr.►u rr;.ua Wall owner /1/'fss r,P�ar N S 6) W 4 f tort.rn trn rAl rCl�[!f� Board of Health permit obtained: ysss no ❑ ""le--sect, w/ WELL use r^wa! WELL DATA Odmestic f ui�ti: Inoustriol Totol well depl(r Mortiloring❑ Dtl er Del/il, to bcdlock T� f1. hlatiroddr{lled Wale( bearing rockJimCun olidaled material: Date drillod ! Descr;ption CASIPIG Wa1cr•beer!ng tones; Type— _l.� _ 1) From—L-34L`To Leny;tiLI !r, Dia(I,D.14in. 21 From— �To Length Into bedrock ft. 3) Fronts_To_ --1 Gravel pack well�Vv dla. ,- Protective w•cll seol:r� V I� _— • Screen: dli Groat.[] 01her STATIC WATER LEVEL(al)wells) S1e11C water level below land surface-J ,_ft Date WELL TEST(product:an wells) Drewdowu,,w.�ft, allay pump)ny ?!ew measured 0 rn n. LOG of FORMATIONS COMMENTS rl'll"'NI from Ta I Driller Firm AOdress City!Town Supervising Dri!ler Req.t1 7 r�iw Pnne rrmry ^+�r o I.i,er,,,a rr irend n�O DilNei — 8 ARD OF HEALTH COPY 03 :34 Pill t. GROUNDWATER ANALYTICAL EPA METHODS 601 and 602 Volatile Organics (GC/PID/ELCD) Field ID: 15l Lab ID: 7545-01 Project: Carleton/Lot 16 Lothrop Batch I0: V02-0370-W Client: Envirotech Sampled: 04-27-94 Cont/Prsv : 40mL VOA Vial/NaHSO4 Cool Received: 04-27-94 Matrix: Aqueous Analyzed: 04-29-94 PARAMETER CONCENTRATION REPORTING LIMIT (ug/L) (u9'L) Dichlorodifluoromethane BRL 5 Chloromethane BRL 5 Vinyl Chloride 8RL 5 Bromomethane BRL 5 Chloroethane BRL 5 Trichlorofluoromethane BRL 1. 1 , 1-Dichloroethene BRL 1 Methylene Chloride BRL 1 trans-1 , Z•-Dichloroethene 8RL I 1 , 1-Dichloroethane BRL 1 cis-1,2-Dichloroethene * BRL 1 Chloroform BRL 1 1 , 1 , 1-Trichloroethane BRL I Carbon Tetrachloride BRL I Benzene BRL 1 1,2-Dichloroethane BRL 1 Trichloroethene BRL I 1 ,2-Oichloropropane BRL I Bromodichloromethane BRL 1 2-•ChloraethyyI Vinyl Ether BRL 5 cis-1 ,3-Dichlorcpropene BRL 1 T.oluene BRL 1 trans-1 ,3-Dichloropropene BRL I 1 , 1 ,2-Trichloroethane BRL a Tetrachloroethene BRL i Dibromochloromethane BRL 1 Chiorobenzene BRL 1 Ethylbenzene BRL 1 meta-and Para-Xylene * BRL 1 ortho-Xylene BRL Bromoform BRL I 1, 1 , 2, 2-Tetrachlorcethane BRL 1 1 ,3-Dichlorobenzene BRL 1 1,4-Dichlorobenzene BRL '- 1,2-Dichlorobenzene BRL QC SURROGATE COMPOUND SPIKED MEASUR1D RECOVERY QC LIMITS a, a, a-Trifluorotoluena 30 32 106 87 - 113 f 1 ,2-0ichloroethane-d4 30 27 91 0 83 - 117 0 8RL = Below Reporting limit. • Non-target compound, Method References: Method SDI Furgeaole KAIocarbont and Method 6OZ - F'urgeable Aromatics, 40 C.F.R. 136, Appendix A (1986) , SEP ti01-99 03 :34 PM � /� ( ] P. 18 I IN OTEC ,jam RIbbi MA Cert, NO.: M-MA 063 ,w9 Rte. 130 - Sandwich, MA 02563 (508) 888-6460 • 1-800-339-6460 FAX (508) 888-6446 LOGATSONi Lot 15 I Robert Carleton Lot:lrops Lane ADDRESS: W. Barnstable skoaU DATE: 4--27-94 DATE RECEIVED: 4-27-94 COLUCT= BY L. Wile SAPTLE ID: 15L 'CDT: WELL DEPTH: 145' 4" PVC JOB #: Nev well 95 static 15 gal/min. pZSTj"f,TS OF ANALYSIS: Qnits Reconnended Result parameters Limit Coliforn bacteria/100m1 ( nitts 5.0-8.5 0 0 PHtuzi7.15 PH umhos/can S00 115 Conductance mg� 28.0 8.5 Sodiun g/L 1010 0.05 Nitrate-Y 013 0.10 Mg/L Iron rq/L 0.05 0.007 Manganese Mg/ as CaCO3 500 17.9 Hardness L50 1 .3 Sulfate Mq/' 20.0 0.7 potassic= Mg/' Z00 14.2 Alkalinity m3/L 250 15.3 Chloride NTUmg/L 5.0 4.0 �irbidity AK units 15.0 LT 1 .0 Color Volatile Organics See attached None Detracted EPA b01/602 �g�" i Yes No WATER IS SUITABLE FOR DRINK SES F PARAMMTRS(�'Y'E TED )OC7C 4. Dater Z T Ron id J. S ri LT = Less Than Laboratory irector T.O.F. AT EL. 127.0' SYSTEM PROFILE TEST HOLE LOGS - ACCESS COVER TO WITHIN 6" OF FIN. GRADE (NOT TO SCALE) ACCESS COVER (WATERTIGHT) TO ENGINEER: DOYLE 126.3 126 MINIMUM .75' OF COVER OVER PRECAST WITHIN 6" OF FIN, GRADE T. McKEAN 2% SLOPE REQUIRED OVER SYSTEM 125 5 WITNESS: RUN PIPE LEVEL 2" DOUBLE WASHED PEASTONE_� 3' DATE. 11/21/96 1 4.35' 3 1500 FOR FIRST 2' MAX PERC. RATE _ < 5 MIN INCH SAND/GRAVEL Focus PROPOSED 122.5 p 124.15' GALLON SEPTIC 123.90' - CLASS I SOILS P# i, TANK (H- 10 ) GAS 123.64' N� 123.5' 0 3.5' ® SIDES BAFFLE 123.81 1.5' ® SIDES ( SLOPE)) "L-6" CRUSHED STONE OR MECHANICAL 2' COMPACTION. (15.221 [2]) 14 oQ Q ELEV, C� DEPTH OF FLOW = 4 ( l % SLOPE) ( 1 SLOPE) " g' oog 121.5' o" 112.0' 0" TEE SIZES: INLET DEPTH = loll 3/4" TO 1 1/2" DOUBLE WASHED STONE TOP & OUTLET DEPTH = 14' SUBSOIL 21.5 LOCATION MAP „ 2' 110 FOUNDATION- 10' SEPTIC TANK D' BOX 16 LEACHING ASSESSORS MAP 109 PARCEL 5-10 9' FACILITY EL. 100.0 SILTY SAND ZONING DISTRICT: RF 4' 108 YARD SETBACKS: I FRONT = 30' _� '32 SIDE = 12' (open space subdiv.) EXISTING � . a WELL N SAND/GRAVEL PLAN REF. - 418/55 FLOOD ZONE: C ENGINEER TO CERTIFY 5' OF SUITABLE IILS BENEATH ELEVATION OF BOTTOM OF LEACHING FACILITY PRIOR TO ANY CONSTRUCTION (HOUSE, RETAINING WALLS AND SEPTIC SYSTEM) 12 NO WATER 100.0' - NOTES: ENCOUNTERED 217 r- - -� NOT AL OIL )_- -___ _� nAT�1M APPROXIMATED FROM QUAD MAP JtF i tL t�� ;IyIV. �GHI<�3A1 t Lii�rC.;ER iS L.- QED __ _ __ +42-958 ` Op N DIRECT ALL RUN-OFF AWAY FROM DESIGN FLOW: 4_ BEDROOMS (110 GPO) = 440 GPD 2. MUNICIPAL WATER IS NOT AVAILABLE - _ E FOUNDATION LOT 9 TEL �`\�\�� -�"�--- _- _+219 SPACE CONTAIN ALL RUN-OFF ON 5' REMOVAL OF USE A 440 GPD DESIGN FLOW 3. MINIMUM PIPE PITCH TO BE 1/8" PER FOOT. RISER \ `127 23 LOCUS UNSUITABLE SOIL MAY BE 1 , REQUIRED AROUND SEPTIC TANK: 440 GPD ( 2 ) = 880 4. DESIGN LOADING FOR ALL PRECAST UNITS TO BE AASHO H- 0 I �\ ` LOT 15 --- �` ` 1{} PERIMETER OF SYSTEM 5, PIPE JOINTS TO BE MADE WATERTIGHT. e 1.7 1 9�!! 36,061 SFt- -�` \ \ �_`. r'; +233 DOWN TO SUITABLE SOIL 1500 1 S J� 1-33 52 USE A __ GALLON SEPTIC TANK \� � LAYER. ENGINEER To -- 6. CONSTRUCTION DETAILS TO BE IN ACCORDANCE WITH MASS. ® 3 !! `_" ,�`� \\� \\ `` 'J��^ 13\� 234 INSPECT AND CERTIFY LEACHING: ENVIRONMENTAL CODE TITLE V. 1 2. 1 �, ` ` '�`` '�\\ `\�\ �' _ 1 +12 .58 SUITABLE SOILS. - a„ -ear`- �� - 2(40.5 + 9.8�) 2 (.74} - 148.9 7. THIS PLAN IS FOR PROPOSED WORK ONLY AND NOT TO BE EXISTING �,` t i 4 SIDES: - WELLS �\\` \ �� z \ �� ` , USED FOR LOT LINE STAKING. o', t \ \ \ \ `� t6'J4r1 N 24373 BOTTOM: 40.5 X 9.83 (.74) - 294 PIP F T T - 1 8. E OR SEPTIC SYSTEM 0 SCH. 40 4" PVC. `. \. 125.5 oRCHl 7 " °' f \ 241 TOTAL: 599 S.F. 443 GPD 9, COMPONENTS NOT TO BE BACKFILLED OR CONCEALED WITHOUT _ .. 04 t 1 i...��. rn t SO!_.- �`�''^ �� „a , `� �� . t s --� 104,E zo �,� \ \ �T INSPECTION BY BOARD OF HEALTH AND PERMISSION ❑BTAINED �` � USE 6 H-20 HIGH CAPACITY INFILTRATORS WITH 3.5' PROP. DWELL. ! FROM BOARD OF HEALTH. pE�K STONE AT SIDES, 1.5' AT ENDS AND 14" UNDER LOT 1a 102 . \'� o , \ 2s. �, / 10. No KNOWN WELLS ARE WITHIN 150' OF PROPOSED LEACH FACILITY e \ _ �22, TOP 127N0'N i I 4 0 NOTE: RESERVE, IF NECESSARY, IS TO CONSIST OF (3) 500 GAL. J LEACHING CHAMBERS WITH 4' STONE AROUND (615 SF) ar- 240 20 '__-. .1or:"EXISHNIG6 4 ,, j f LEGEND I00. 2 I �;� \ - SITE PLAN a \ WELL. �\ \ o\ C` 10 ` 0 <5 • ` _ '� ram!//-�� 110.02 100.0 PROPOSED SPOT ELEVATION OF 115.15 ' BENCHMARK _�; 56 LOTHROP S LANE CATCH BASIN + ?4 !' ' 115,76 1 OOXO EXISTING SPOT ELEVATION ELEV = 99.38' ��\\ r7.. 0 1 � �E]r \ iis22' 100 IN THE TOWN OF: A 11 U, PROPOSED CONTOUR (WEST) BARNSTABLE N PROP. RpCF: RETAINING WALLS (VARIABLE HFIGHT) 100 EXISTING CONTOUR 2()4 25 PREPARED FOR: MAINE POST AND BEAM y� J00.6 AT +108.65 IS y 4 J) \\�� 1 ' I �� ELEC PAD LOT 14 40 0 40 80 120 Feet I 103 NRC*20- ELECTRIC BOARD OF HEALTH 102.6 MANHOLE COVER APPROVED DATE MA SCALE: 1" = 40' DATE: JANUARY 18, 2000 NOTE: OPEN SPACE SUBDIVISION REV. 2/29/00 (MOVE H5E) / OPEN SPACE = 663,418 SF off 508-362-4541 # LOTS = 37 fax 508 362-9880 663418/37 = 18,428 SF I �P`H Of SJ9 ��1N Of � Mq SQUARE FOOTAGE APPORTIONED TO EACH LOT FOR down cape engineering, Inc. '' ARNE rya ARNE H. cGr NITROGEN CALCULATION PURPOSES: 18,428 SF H. OJALA '=+ EXISTING LOT = 36061 SF CIVIL ENGINEERS O.JAB . +18428 SF No. 26348 �q No. 30707 92 54489 SF LAND SURVEYORS Cl 99--296 939 main st. yarmouth, ma 02675 ARNE H. OJALA, P. ., P.L.S. DATE ----------