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HomeMy WebLinkAbout0164 LOTHROP'S LANE - Health 164 Lothrop's Lane West Barnstable A = 110 — 025 —011 M Commonwealth of Massachusetts lip Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments I` ;V 164 Lothrop's Lane Property Address John & Lynda Comolli Owner Owner's Name information is West Barnstable MA 02668 2-14-19 ', 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. p0I\A OF/ iii����� Important:When A. Inspector Information �/ fig- ,�°� filling out forms `a� �;'' •. y on the ,com uter O G p James D.Sears JAM ES rn= use only the tab key to move your Name of Inspector cursor-do not Ca ewide Enterprises use the return Company Name •�' �:' key. 153 Commercial Street ��; IN5?"-°°��` ray Company Address 11111 Mashpee MA 02649 City/Town State Zip Code 508-477-8877 S1623 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3.• ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails a'�Vz.za_ � 2-16-19 spector'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 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 form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: 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. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments t % 164 Lothrop's Lane u Property Address John & Lynda Comolli Owner Owner's Name information is required for every West Barnstable MA 02668 2-14-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) 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: The system is a 1500 Gal. Tank D Box and two pits, 2) 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): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts 1, Title 5 Official Inspection Foam �o Voluntary Subsurface Sewage Disposal System Form -Not for Y y Assessments 164 Lothrop's Lane Property Address John & Lynda Comolli Owner Owners Name information is every West Barnstable required for eve MA 02668 2-14-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ 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): 3) 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. a. 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: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 c Commonwealth of Massachusetts Tine 5 Official Inspection Form ` Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 164 Lothrop's Lane Property Address John & Lynda Comolli Owner Owner's Name information is required for every West Barnstable MA 02668 2-14-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ 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 b. 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. c. Other: 4) 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 164 Lothrop's Lane Property Address John & Lynda Comolli Owner Owner's Name information is required for every West Barnstable MA 02668 2-14-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in Is less than 6" below invert or available volume is less than '/z day flow P/s- ❑ ® 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 water supply 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 2000 gpd- 10,000 gpd. ❑ ® 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. 5) 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 CA. 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 11 of a public water supply well t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 164 Lothrop's Lane Property Address John & Lynda Comolli Owner Owner's Name information is required for every West Barnstable MA 02668 2-14-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes"to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate "yes" or"no" for each of the following for all inspections: 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)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 cam, Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 164 Lothrop's Lane Property Address John & Lynda Comolli Owner Owner's Name information is required for every West Barnstable MA 02668 2-14-19 page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): NA Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 Description: 1500 Gal. Tank D Box and two pits. 2 Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information'in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Well Water Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Present Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 164 Lothrop's Lane Property Address John & Lynda Comolii Owner Owner's Name information is required for every West Barnstable MA 02668 2-14-19 page. City/Town State Zlp Code Date of Inspection D. System Information (cont.) 2. 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 Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available.- Last date of occupancyluse: Date Other(describe below): 3. Pumping Records: Source of information: NA Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5nsp,doc•rev.7126/2016 Title 5 Of ial Inspection Form:Subsurface Sewage Disposal system•Page a of le abed xed dH 90:9 6 6 L02 8 6 qad Commonwealth of Massachusetts kp Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments vw� p 164 Lothrop's Lane Property Address John & Lynda Comolli Owner Owner's Name information is West Bamstable MA 02668 2-14-19 required for every page, Ci j/Town State Zip Code Date of Inspection D. System Information (cont.) 4. 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): Approximate age of all components,date installed (if known)and source of information: 1993 Permit#93-6861 1 2-201 5 new D Box. Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. 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.): P,ipeing is 4" PVC SCH-40 t5insp.doc-rev,7/2 012 0 1 8 Ttle 5 Dfidal Inspection Form;Subsurface Sewage Disposal System•Pape 9 of 18 Z a6ed xed dH 90:91, 61,0Z 81, cad Commonwealth of Massachusetts ,p Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 164 Lothrop's Lane `-' Property Address John & Lynda Comolli Owner Owner's Name information is West Barnstable MA 02668 2-14-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): 14" 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 Gal. Precast H-10 1" Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 29" 0" Scum thickness Distance from top of scum to top of outlet tee or baffle 8" Distance from bottom of scum to bottom of outlet tee or baffle 18" How were dimensions determined? Asbuilt-Tape 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.): Tank at working level. Tank at 14" below grade w/covers at 6". In and outlet tees. No sign of over loading or leakage t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form l.N Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 164 Lothrop's Lane Property Address John & Lynda Comolli Owner Owner's Name information is required for every West Barnstable MA 02668 2-14-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 c Commonwealth of Massachusetts 1 Title 5 Official Inspection Form < Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 164 Lothrop's Lane Property Address John 8r Lynda Comolli Owner Owner's Name information is required for every west Barnstable MA 02668 2-14-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) 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 9. 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.): D Box is 16"x16"-18" below grade w/cover at 6". Box is New 12-2015 w/two lines out. Box is clean and solid w/no sign of over loading or solid carry over. 15insp.doc•rev.7/25/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 164 Lothrop's Lane u Property Address John & Lynda Comolli Owner Owner's Name information is West Barnstable MA 02668 2-14-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. 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. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 2 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Forums SSubsurface Sewage Disposal System Form -Not for Voluntary Assessments 164 Lothrop's Lane Property Address John &Lynda Comolli Owner Owner's Name information is West Barnstable MA 02668 2-14-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching is two 1000 Gal. Precast pits. Pit# 1 at 5' below grade w/cover at 10"-6"water in pit. Pit#2 at 7' below grade w/cover at 3'. 4"Water in pit. No sign in pits of over of over loading or solid carry over. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): tIinsp.loc•rev.7/28/201, Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 164 Lothrop's Lane Property Address John & Lynda Comolli Owner Owner's Name information is required for every West Barnstable MA 02668 2-14-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. 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.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts Title 5 official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 164 Lothrop's Lane Property Address John & Lynda Comolli Owner Owner's Name information is required for every West Barnstable MA 02668 2-14-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. 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 A r? A� 7 O a- /3 A3 0 f yl �8 t5insp.doc•rev.7/2 6110 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 164 Lothrop's Lane Property Address John & Lynda Comolli Owner Owner's Name information is required for every West Barnstable MA 02668 2-14-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells No 20'+ Estimated depth to high ground water: 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: Area high 20.+ Bottom of pit 2 at 13' below grade. Before filing this Inspection Report, please see Report Completeness Checklist on next page. 151nsp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Foam Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 164 Lothrop's Lane Property Address John & Lynda Comolli Owner Owner's Name information is required for every West Barnstable MA 02668 2-14-19 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6(Checklist)completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included �v o G": w t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 °'c 09 2015 21:12 Jim The Inspector Man 5085349919 page 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments e^•3 'f 164 Lothrop's Lane lr Property Address l "; John & Lynda Comolli ' Owner Owners Name / information is West Barnstable t/ MA 02668 12-9-15 �- required for every page. City/Town State Zip Code Date of inspection w 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 # ����d1tu1101Fingi/,� �� , 1 3ti z� on the computer, / � ``���� .........S� use only the tab �5F ' C 1. Inspector: o .•y key to move your JA M ES N cursor-do not James D.Sears use the return Name of Inspector SEARS - key. Capewide Enterprises, LLC s*A o o "I�--y1 Company Name ���i�'�4�i(SRf N•P�'\�`����� 153 Commercial Street ����,...._______ ..••�� j Company Address Mashpee MA 02649 City/Town State Zip Code 508-477-8877 S 1623 I Telephone Number License Number B. Certification F i I certify that I have personally inspected the sewage disposal system at this address and that the r. 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 12-9-15 ,oFspector'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 sprit 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 y the same or different conditions of use. t5ins•3112 Title 5 Official Inspecfion Form:Subsurface Sewage Disposal System•page 1 of 17 kpgc�zd VS 00 Ded 09 2615 21:12 Jim The Inspector Man 5085349919 page 2 Commonwealth of Massachusetts a Title 5 Official 'inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 164 Lothro 's Lane Property Address John &Lynda Comolli Owner Owner's Name information is West Barnstable MA 02668 12-9-15 required for every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E I 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: The system is a 1500 Gal.Tank D Box and two pits 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•3013 TWO 5 Official Inspeclion Foam:Subsurface Sewage Disposal System Page 2 of 17 Ded 09 2615 21:12 Jim The Inspector Man 5085349919 page 3 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments r 164 Lothro 's Lane Property Address John &Lynda Comolli Owner Owner's Name information is required for every West Barnstable MA 02668 12-9-15 page. City/Town State Zip Code Date of Inspection B. Certification (cunt.) ❑ 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 ❑ NO (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ NO (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 ❑ NO (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 15ins•3/13 Tile 5 Official Inspecdon Form:Subsurface Sewage Disposal System•Page 3 of 17 ee 09 2615 21:12 Jim The Inspector Man 5085349919 page 4 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 164 Lothro 's Lane Property Address John & Lynda Comolli Owner Owner's Name information is MA 02668 12-9-15 West Barnstable required for every State Zip Code Date of Inspection page Citylrown B. Certification (cost.) 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 c oliform 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 El ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in is less than 6" below invert or available volume is less _ than %day flow P/ -5 t5ins•3113 Tills 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 ec. 09 2015 21:12 Jim The Inspector Man, 5085349919 page 5 Commonwealth of Massachusetts Title 5 Official Inspection Form a - Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r 164 Lothro 's Lane Property Address John & Lynda Comolli Owner Owner's Name Information is required for every West Barnstable MA 02668 12-9-15 page. CitYrTown 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. 15ins.3/13 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Dec 09 2015 21:12 Jim The Inspector Man 5085349919 page 6 Commonwealth of Massachusetts Title 5 Official Inspection Form c Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 164 Loth rop's Lane Property Address John & Lynda Comolli Owner Owner's Name information is required for every West Barnstable MA 02668 12-9-15 page. CitylTown 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? El ElWere 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: z ❑ 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): NA Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 t5ina•3/13 Title 5 Official Inspection Form:Subsulace Sewage Disposal System•Page 6 of 17 ec 09 2b15 21:12 Jim The Inspector Man 5085349919 page 7 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 164 Lothro 's Lane Property Address John & Lynda Comolli Owner owner's Name information is West Barnstable MA 02668 12-9-15 required for every State Zip Code Date of Inspection page Citylrown D. System Information Description: The sstem is a 1500 Gal Tank D Box and two pits. 2 Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection El Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? El Yes ® No Water meter readings, if available(last 2 years usage (gpd)): Well Water . i Detail: Sump pump? ❑ Yes ® No Present Last date of occupancy: Date Commemlalllndustrial Flow Conditions: i 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 Tioe 5 Official Inspection Form,Subs lace Sewage Dlsposal System•Page 7 of 17 ec 09 2015 21:13 Jim The Inspector Man 5085349919 page 8 Commonwealth of Massachusetts 1.001 Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 164 Lothro 's Lane Property Address John &Lynda Comolli Owner Owner's Name information is required for every West Barnstable MA 02668 12-9-15 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: 2011 /2014 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): 15ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 0 of 17 Dec 09 2015 21:13 Jim The Inspector Man 5085349919 page 9 Commonwealth of Massachusetts Title 5 Official Inspection Form " s Subsurface Sewage Disposal System Form -Not for voluntary Assessments " 164 Lothro 's Lane. Property Address John & Lynda Comolli Owner Owner's Name information is required for every West Barnstable MA, 02668 12-9-15 page. CitylTown Slate Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 1993 Permit # 93 -686 1 12-2015 New.D Box. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 2' Depth below grade: 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.): Pipeing is 4" PVC SCH 40 Septic Tank(locate on site plan): 14" 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 Gal. Precast H-10 1„ Sludge depth: 15ins•3113 Tille 5 official Inspection Forth:Subsurface Sewage Disposal Syslem-Page 9 of 17 , Dec 09 2015 21:14 Jim The Inspector Man 5085349919 page 10 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 164 Lothro 's Lane Property Address John & Lynda Comolli Owner Owner's Name information is west Barnstable. MA 02658 12-9-15 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 29" Scum thickness 8„ Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 17" Asbuilt-Tape How were dimensions determined? 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.): Tank at working level. Tank at 14" below grade w covers at 6". In and outlet tee's. No sign of over loading or leakage 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 16ins•3113 Tige 5 Official Inspeclion Form:Subsurface Sewage Disposel System•Page 10 of 17 Dec 09 2015 21:14 Jim The Inspector Man 5085349919 page 11 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 164 Lothrop's Lane Property Address John & Lynda Comolli Owner Owner's Name information is required for every west Barnstable MA 02668 12-9-15 page. Citylrown State Zlp 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•2/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 ec 09 2015 21:14 Jim The Inspector Man 5085349919 page 12 c Commonwealth of Massachusetts = Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 154 Lothrop's Lane Property Address John & Lynda Comolli Owner Owner's Name. information is required for every West Barnstable MA 02668 12-9=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.): D Box is 16"x16"-18" below grade w/cover at 6" Box is new 12-2016 wltwo lines out. 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: 15ins-3113 Title 5 Official Inspedion Form:Subsurface Savage Disposal System-Page 12 of 17 et 09 2015 21:14 Jim The Inspector Man 5085349919 page 13 Commonwealth of Massachusetts Title 5 Official Inspection Form i . Subsurface Sewage Disposal System Form-Not for Voluntary Assessments y. 164 Lothro 's Lane Property Address John & Lynda Comolli Owner Owner's Name information is west Barnstable MA 02668 12-9-15 required for every State Zip Code Date of Inspection page. Cityrrown D. System Information (cont.) Type. 2 ® leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching is two 1000 Gal. Precast Pits. Pit#1 at 5' below grade wlcover at 10"-6"water in pit. Pit #2 at 7' below grade wlcover at 3',1'water in pit No sign in pits of over loading or solid carry over. 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 111119 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Dec 09 2015 21:15 Jim The Inspector Man 5085349919 page 14 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments `. 164 Lothro 's Lane Property Address John & Lynda Comolli Owner Owner's Name information is West Barnstable MA 02668 12-9-15 required for every CltylTown State Zip Code Date of Inspection page. 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.): 15ins-3/13 Title 5 Ofliclal Inspecilon Form:Subsurface Sewage Disposal Sysiem•Page 14 of 17 T HE FOLLOWRNG IS/ARE THE BEST IMAGES FROM POOR QUALITY ORNGIIHALCS) A �C(�J L Dec 09 2015 21:15 Jim The Inspector Man 5085349919 page 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments, 164 Lothrop's Lane Property Address John & Lynda Comolli Owner Owners Name information is West Barnstable MA 02668 12-9-15 required for every page. City/Town Stale 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 � �A 06 o1 :L 0 0 t A -3= 3,t 0 0 3 j -S O 411-6 Pf ' r tame-W13 Teo S orfidar W09c6m Fo m:subawrem so~olspow 6yslom-Pepe 1a al 17 i Dec 09` 2015 21:15 Jim The Inspector Man 5085349919 page 16 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 164 loth ro 's Lane Property Address John &Lynda Comolli Owner Owner's Name information is West Barnstable MA 02668 12-9-15 required for every State Zip Code Date of Inspection page Cityrrown D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells N4 '� 20'+ Estimated depth t high ground water: 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: Area high 20'+ Bottom of pit 2 at 13' below grade Before fliing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3113 Title 5 Official Inspeclion Fwm SubsuAace,Sewage Disposal System•Page 16 of 17 Dec 09 2015 21:16 Jim The Inspector Man 5085349919 page 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 164 Lothro 's Lane Property Address John&Lynda Comolli Owner Owner's Name information is West Barnstable MA 02658 12-9-15 required for every State Zip Code Date of Inspection page. 6ityfTown E. Report Completeness Checklist ® Inspection Summary: A, B. C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 6 Official Inspection Fome Subsurface Sewage Disposal System•Page 17 of 17 No.c/"U/5 � Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 01pplitation for -Misposal *pstrm Construrtiun Permit Application for a Permit to Construct( ) Repair()4 Upgrade( ) Abandon( ) ❑Complete System WIndividual Components Location Address or Lot No. J 6`i (,eTqP C D S LAO&- Owner's Name,Address,and Tel.No. Assessor's Map/Parcel 0 D — o f l - P 0l-3 d C 5®�` fs7j4-&A� Installer's Name,Address,and Tel.No. 0g—((Z7— 8$-71 Designer's Name,Address,and Tel.No. Cr;4®EW1)C— C C 6S u..P Nl Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) RQP(, _G; ID"BOtle Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Heal Signed Date r l Application Approved by Date 3 Application Disapproved by Date for the following reasons Permit No. — Date Issued >3 No.�/✓ _ 9 Fee / THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 01ppYitation for Disposal 6pstem Construction Permit Application for a Permit to Construct( ) Repair(X Upgrade( ) Abandon( ) ❑Complete System Nf Individual Components Location Address or Lot No. 1 (,oikP(71)$ LA06' Owner's Name,Address,and Tel.No. 1n1 T3 ZT044 CdYrOc.(,i Assessor's Map/Parcel Po (30)< 'off -1 E � Installer's Name,Address,and Tel.No. 5109-(417- 2T5-71 Designer's Name,Address,and Tel.No. deADEc1VI_r,>G— Type of Building: Dwelling No.of Bedrooms y Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) '� Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date ; Title Size of Septic Tank Type of S.A.S. Description of Soil t �l Nature of Repairs or Alterations(Answer when applicable) pRCP LJ D—box Date last inspected: , Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Heal i Signed Date Application Approved by Date �� 3 Application Disapproved by Date for the following reasons Permit No. G Date Issued 13 ------------------------------------------------------------------------------------------------------------------------------------ THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS (Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(�) Upgraded( ) Abandoned( )by CAP i✓u3 m C C-_07GOK6r�: at I(OL-4 (,(T(�'�RC7(� S L64-JE w 6 has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No� ei L�Ut dated 5 Installer`A1PG �(n� L CS U-1 Designer 1�LA #bedrooms Approved desig V`� gpd 4 1 The issuance o this permit shall not be construed as a guarantee that the system wil nction designed. Date , ). Inspector ---------------------- --------------------------------------------------------------------------------------------------/-------------- No. G c)GS Fee THE COMMONWEALTH OF MASSACHUSETTS --�( -� PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Disposal 6pstem Construction Permit Permission is hereby granted to Construct( ) Re air(x) Upgrade( ) Abandon( ) System located at (04 L ci ( H RO S ( (V G 1•i} 6-r PAR40�;-rA6 C6 and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this pe it. Date /� .3// Approved by Health Complaints 06-Sep-02 Time: 1:00:00 AM Date: 7/8/02 Complaint Number: 3518 Referred To: LEE MCCONNELL Taken By: FLORENCE SMITH Complaint Type: GENERAL Article X Detail: Business Name: Number: 164 Street: Lothrops Lane Village: WEST BARNSTABLE Assessors Map-Parcel: Complaint Description: Mr. Comalli is dumping dead fish & lobster tails on the property line and it smells bad. Actions Taken/Results: LM investigated complaint 07/10/2002. Mr. Comalli uses the old fish heads and shellfish for his plants and garden. Lm suggested storing the carcesses and shellfish in another spot so not to disturb the neighbors. Lm did not smell an odor on site Investigation Date: 7/10/02 Investigation Time: 3:45:00 PM 1 V TOWN OF BARNSTABLE LOCATION ���� Qnq��i� �� SEWAGE # VILLAGE Ecc�L - � � ,cc�nS a ASSESSOR'S MAP & LOT I+o NNSTALLER'S NAME & PHONE NO. ��,yS�.c� Q,4�-2�c� i I SEPTIC TANK CAPACITY K-00 aS-1 �LEACHING FACILITY:(type) F120 LC (size)�� %QO. OF BEDROOMS 4 PRIVATE WELL OR PUBLIC WATER_ BUILDER OR O WNE DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No '� ,. yz z ® 'V w No Fimic ....l.d. ...... THE COMMONWEALTH OF MASSACHUSETTS _ BOAR® OF HEALTH ---------- ---------OF....... (-............................................... ApplirFatiou for M-4posFal Work.6 Tonstrurfiuit Vinuat Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal System at: .1.h ..... ....... .........04....3 --------------- ----- ------------- ...------.....-------.....----....------- J_ Loc,rraiion-Ad/dress 1�, 7 or t _________________________ _______ �"'� ...'�lb..... ..IlIL�I?.._..._......_.........._ .... ow r ' Addres a ............. ---. c _ s f ------- ----- ............. Installer Address Type of Building Size Lot.... .7.�.-W.........Sq. feet Dwelling—No. of Bedrooms........ ................______..........Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building _______.... No. of ersons____________________________ Showers SS •p ( ) — Cafeteria (. ) Other fixtures --------•--------- w Design Flow______.____ gallons per person per day. Total daily flow............. .....................gallons., WSeptic Tank—Liquid capacity/S!®__gallons Length...!A__o...... Width__.(n__.___.___ Diameter________________ Depth................ Disposal Trench—No_ ____________________ Width.................... Total Length.................... Total leaching area....................sq. ft. ' Seepage Pit No.____a--_________ Diameter......10.________. Depth below inlet_____ ___________ Total leaching area._.�?.ftv.____sq--it y'a. Z Other Distribution box ( ) Dosing tank ( ) `~ Percolation Test Results Performed by___Un...Zkyk........ _______________ Date..........................._...... __._-. Test Pit No. 1---0�--------minutes per inch Depth of Test Pit---1, .......... Depth to ground water_4?*f&.. G� 44 Test Pit No. 2............_---minutes per inch Depth of Test Pit.................... Depth to ground water........................ x 0 Description of Soil•A� c� ------------------------------------------------------------------------------------------------------------------------------------------------------------------------ ----- w UNature of Repairs or Alterations—Answer when applicable-------------------------_......................._.................................. _____________ •-----------------------------------------------•------------------------------•-------.....-------•----•----------------------------------------------•------------•--------------------------...----•- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iI'= 5 of the State. Sanitary Code—The undersigned further agrees not to place the system in ,operation until a Certificate of Compliance has b issu by the,board of health. Signed_ ...12'/ '...3. .._..... Date Application Approved BY C� - 8 9• Date Application Disapproved for the following reasons:................................................................................................................ ----------------------------------------•------------•------•-------••-••-----•-•----------------•-----------------•••-•-•--••-----------•---•----------------•-----------•--------•------•-------_-_--- Date PermitNo. -- = '-----•------------ Issued--------------------------=---------------------------- Date k No........ ... .......... Fxs............._............... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ......................OF.......�`►' ��� `�� t9,,It� .............................................. Appliration for Dispaii al Works Tontrur#ion Permit Application is hereby made for a Permit to Construct (N-or Repair ( ) an Individual Sewage Disposal S stem at* �;�Fg} �j1�IJ• �b I Z ................... .. ---------- - y, .( rr f 1 i5 i�1--j&k o:itiilf�.............................. ^+ Loc on-Address {•-.U Yb j AA1DLv!t, jq -- t-+�'Ir 9 �9... --•----------------------•------••-------••-.......................... Owner / Add�es►�_l � � a ---•-c, y•i;a T:r '•-•......... .-- € -•----f•...... ...............•-•-----•--....... ....._......- ----- - Installer Address d Type of Building Size Lot.................----------Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) p-I Other—Type of Building ............................. No. of persons............................ Showers ( ) — Cafeteria ( ) Pa Other fi res ••----•--••-•-•-••------•-••--•. W Design Flow.................................fj.-,9.a-_gallons per person pier"day. Total duly flow............................................gallons. 1:4 Septic Tank—Liquid capacity............gallons Length.............•.. Width................ Diameter---------------- Depth................ Disposal Trench—I�--.--•-----___---•-- Width.v6-i............. Total Length...........:_..... Total leaching area............>.......sq. ft. Seepage Pit No--------------------- Diameter-------------------- Depth below inlet.................... Total leaching area...._'_.. . ...sq'"I"t"" 00D' Z Other Distribution box ( ) Dosing tank ( ) ~' .Percolation Test Results , Performed '� ...............'Afl A,!l1 ��. -- f2 . 2P5.------.... Date........................................ Y--...••. ... as Test Pit No. 1................minutes per inch Depth of Test Pit--------12. ..... Depth to ground water.._..!'x:_. Gz, Test Pit No. 2................minutes per inch Depth of Test Pit..................... Depth to ground water-------................. R� 4 I,---;----------------------------------------------•-------------------------------.--------•-----------------------.-------------•-•------•--------------•-- ODescription of Soil----•- W-r:rA�...................................................................................................................................................... x w •----•-•••------------------••-••--•••---•-•----•---•----•-------•--------•-•-----------•--•----•-•----•--••--•-•-------•-••-•-•------••-------•---•••--••••••--•-••----•-••-•-••--•-•......-•------••-- VNature of Repairs or Alterations—Answer when applicable............................................................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITIE- 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been/issued by the board of health. Signed-..•.�-=�.......................` . f }y 3 ZJ .. Application Approved BY .�........... ...----•-•--•••......--- .... D t Date Application Disapproved for the following reasons:................................................................................................................ �� Date .Xermit No.....•••--3...e... vim.. - Issued.......................................... ate....... Date THE COMMONWEALTH OF MASSACHUSETTS ,r BOARD OF HEALTH � •K.............OF.......... ........................................................................_. Tntifiratr of Team rliFanrr THIS IS TO CEg TI That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by........................... ...........................-................................................................................................................................. n......r at_...--••--..dZ�...... w has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No......................................... dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTI N SATISFACTORY. DATE.......... - �- ------------------------ Inspector.----------- - ........ THE COMMONWEALTH OF MASSACHUSETTS BOARD QbF HEA T .................................. ..OF.................................................................................... No......................... FEE........................ Disposal nr#ion Permit Permission is reb ranted -••----- Yg rr to Construct ( ) oZJ p.fr �. 6,an jjn Ji6"ge Pieposal �em V'.Jo•�� atNo......................................................................__..---...--•••---......_.__.........----••--•-••--Street as shown on the application for Disposal Works Construction Permit J No._______ _._�_. Dated.......................................... L - •-------•-------------•--•--.......--•-•-----....._._..••.-•--._ t,_— / J ?_�) Board of Health DATE............................................................................... FORM 1255 A. M. SULKIN, BOSTON LU Department of Environmental Management/Division of Water Resources 6 i` WATER WELL COMPLETION REPORT Wy ELL LOCATION' Address) City/Town GCS A k l 1 C r �A r G.S.Quadrangle Map 1,41 Grid Location Owner- � h M a If v Address_ WELL USE CONSOLIDATED WELL Domestic' Public ❑ Industrial ❑ Type of Water-bearing Rock u Other Water-bearing Zones ' Method Drilled A 1) From 10 To f� 2) From-To- Date Drilled /riii � 91 31 From To , 4) From-To- CASING r Depth to Bedrock Alf,40 Length g& Diameter, Type CIY ` UNCONSOLIDATED WELL t STATIC WATER LEVEL Water=bearing Materials Feet below land sur ace ! if Sand: fine❑ medium❑ coarse❑ Y.Date measured Gravel: fine.[] medium❑ coarse❑ Screen: GRAVEL PACK WELL Slot#length fro _tgW Yes ❑ IN f P Split Screen(or 2nd screen) WATER QUALITY TESTS MAD Slot length from to Chemical �'� Biological Depth To Bedrock P GPM. PU a s h urs g �� Drawdown feet after um in at��"� How measured Recovery feet after hours. LOG of FORMATIONS COMMENTS: (On well or water) Materials From To 0 Z a ° S I9Jt�t� �V 14 U / I R I L L E=RCb 9 Fir??.; V0 (lsi•/�•.i[/ ° �r , a y Adl o I't#9(A ` 9 city / T/ ► r 1/ aka /®p - " Registratiol No. #� "peato ignature q, Please pant irm y ` 25M•10.85'807101 9; ` BCSA_ _ _OF HEALTH COPY � .r.: i GROUNDWATER ANALYTICAL EPA METHODS 601 and 602 Volatile Organics (GC/PID/ELCD) Field ID: Z162 Lab ID: 6530-01 Project: Commoli 26 Lothrop Batch ID: VG3-0159-W Client: Envirotech Sampled: 12-01-93 Cont/Prsv: 40mL VOA Vial/NaHSO4 Cool Received: 12-02-93 Matrix: Aqueous Analyzed: 12-02-93 PARAMETER CONCENTRATION REPORTING LIMIT (u5/L) (u9/L) Dichlorodifluoromethane BRL 5 .� Chloromethane BRL 5 Vinyl Chloride BRL 5 Bromomethane BRL 5 Chloroethane BRL 5 Trichlorofluoromethane BRL 1 1,1-Dichloroethene BRL 1 Methylene Chloride BRL 1 tran,s-1,2-Dichloroethene BRL 1 1,1-Dichloroethane BRL 1 cis-1;2'Dichloroethene * BRL 1 Chloroform BRL 1 1,1, 1-Trichloroethane BRL 1 Carbome,36trachloride BRL 1 Benzene BRL 1 1,2-Dichloroethane BRL 1 Trichloroethene BRL 1 1,2-Dichloropropane BRL 1 Bromodichloromethane BRL l 2-Chloroethyl Vinyl Ether BRL 5 cis-1,3-Dichloropropene BRL 1 Toluene BRL 1 trans-1,3-Dichloropropene BRL 1 1,1,2-Trichloroethane BRL 1 Tetrachloroethene BRL 1 Dibromochloromethane BRL 1 Chlorobenzene BRL 1 Ethylbenzene BRL 1 meta-and para-Xylene * BRL 1 ;ortho-Xylene * BRL 1 Bromoform BRL 1 1, 1,2,2-Tetrachloroethanek;'° BRL 1 1,3-Dichlorobenzene BRL 1 1,4-Dichlorobenzene BRL 1 1,2-Dichlorobenzene BRL 1 QC SURROGATE COMPOUND SPIKED MEASURED RECOVERY QC LIMITS a,a,a-Trifluorotoluene 30 27 89 % 87 - 113 1,2-Dichloroethane-d4 30 30 102 % 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). ENVIROTECI-I LABORATORIES Mass. Cert.#:MA063 449 Route 130 Sandwich,MA 02563 a (508) 888-6460 CLIENT: John Commoli LOCATION: Lot 26 Lothrops Lane ADDRESS: W. Barnstable, MA COLLECTED BY: L. Wile SAMPLE DATE: 12-1-93 TIME: DATE RECEIVED:12-1-93 SAMPLE ID: Z162 JOB#: New well WELL DEPTH: 120' 4"PVC 64' Static water 25G.P. RESULTS OF ANALYSIS: Parameter Units Recommended limit Result Coliform bacteria/100 ml (MF Method) 0 0 pH pH units 6.0-8.5 6.83 Conductance umhos/cm 500 82 Sodium mg/L 28.0 9,9. Nitrate-N mg/L 10.0 0.06 Iron mg/L 0.3 0.58 Manganese mg/L 0.05 0.06 Hardness mg/L as CaCO, 500 15.0 Sulfate mg/L 250 0.69 Potassium mg/L 20.0 2.6 Alkalinity mg/L 200 18.2 Chloride mg/L 250 16.2 Turbidity NTU 5.0 18.8 Color APC units 15.0 <1.0 Background bacteria/100 ml QAF method) 200 EPA 601/602 * N.D. COMMENT: * See report attached. YES NO )M ❑ WATER IS SUITABLE FOR DRINKING PURPOSES FOR P ETERS TESTED.DATE/ Z- I6 R _—- Fee-�---------------- t BOARD OF HEALTH nr TOWN[ OF BARNSTABLE ` Z.ppYitationfforlVelt Con5tructionpermit Application is her by made or ermit o Construct ( ), Alter ( ), or Re pa' ( )an individu Well at: Locate dr s Assessors Map and Parcel �� S ,� -`------- wner Address n P6 A Y,,6 -- ---- ---------- r►�fi ----- ----------------------------------------------------------------------------- Installer — DrillerPAY Address Type of Building �ft Dwelling------------------- - — - ---------------- Other - Type of Building --------------- No. of Persons--------------------------------------------------------- �l. Typeof Well- _PVC, .- -------—------------ Capacity--------------------------------------------------------------- - Purpose of Well-------- ---------------------------- Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation — The undersigned further agrees not to place the well in operation unti a Certificate of Complianec�qh s been issued by the Board of Health. �1 Signe -C -"' ----------------- ------------------------------------- date . ice' D ,' p `3 Application Approved By- �"'��r! -=-== — ---- - -- r �date " Application Disapproved for the following reasons:----------------------------__--------__------------_-_--__-__---------------------------------__ ----------------- --------------------—-------- - - ----—-------— -- --- date Permit No. - ---� -- --------------------- Issued--- •✓ t� -------- date BOARD OF HEALTH TOWN OF BARN[ STABLE (Certificate Of Compliance THIS /�,01 C#.RTIFY That the Individu 1 Well Constructed (�/�ltered ( ), or Repaired ( ) by��Sld'1 _ - -- X %-1105 _t— y-e-��- - -- ---- - - - .. ------------------------ Installer Q at- -- L?----- �_�'Q.�-�-----�4-�/�-------�------�.-� - -� C 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 Perm 44Cdr1 Dated THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE----------------— -- -------------------- ------------------------ Inspector-------------------------------------------------------------------- / s' -� i Fee 6�------------- BOARD OF HEALTH 4 TOWN OF BARNSTABI:E ' . zipplicat ion Ar Veil Con6truct ion 3Permit Application is hereby made or1 a�jpeermit Jto Construct ( ), Alter ( ),qor Repair ( )an individual Well at: _ � " -- - -- -- - - ------------- Assessors Map and Parce Location — Addres"s -------------------------=----------------------- -- — —U Address Owner '--- ---��-S> ---- - - — —— i rµ� Address Installer — Driller Type of Building t L -A(:) oVJ Dwellin --------- ------------- - - ------------- - No. of Persons-------— -----— — — Other - Type of Building-------------- - - tP �j Type of Well ----------- Purpose of Well-------- - - ---- - -- ---------------- Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation — The undersigned further agrees not to place the well in operation until a Certificate of Compliance.,has been issued by the Board of Health. Signed -, date Application Approved By-------------_------------- -- """--- � �. —date--`_____ Application Disapproved for the following reasons:----------------------- - —--- — ----"-—" -- — — -- ---------- --------—— — —— — —— ---- —-- _______-------- — date --—— Permit No.--,7 /_ ___ - - -— Issued--------f =tea t—_-�_ ---- —- BOARD OF HEALTH TOWN OF BARNSTABLE Certifitate (Df COMP iauce THIS IS TO CERTIFY That the Individual Well Constructed (6,-), Altered ( ), or Repaired ( ) br /�� _ - M- --�1---`C----------------------------- ---_ --- -- y_________�—__________,., Installer at - -= ----- ��- - °--- - - - has been installed in accordance with the provisions of the Town;of Barnstable Board of Health Private Well Protection Regulation as described in the application for Well Construction PermiT ',-��� '-� - - Dated f� 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 BARNISTABLE- JVeir Congtruction3Permit Fee--------- No.---------------------- C Permission is hereby granted---=-- ------�----�=-__J,L�►'�------------------------------------------------------- --- ---------- -------------- to Construct (`/'�)� f�Allter ( ,)/,T or pair ( ) an Individual Well at40 T-6!s )6th ADO R __ ------------------ —f = — ------=s' ----AV- No. -- -- Street �4?� as shown on the application for a Well Construction Permit 4F 1_:: -----e - ---------------------------- Dated------------ ----'f - Board of Health DATE------------------------ /f-" ��` --------------- l� c. 3 � 7o 7a, G8' 0 7y 1 osc L07- L o 7 Lk oe SI/vGLE Fih I-( i LY - �3ED 20 o M S N 3 s, M O &^rLe)FI G-E 7 I S two S/� 2'd DA ILY (--Lm/ _ ► I U x 4 = 4 4o C-, P. D. 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