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1837 MAIN ST./RTE 6A(W.BARN.) - Health (2)
1837 Main Street/Route 6A, West Bai•nstab;e"Sm A= 4 TOWN O�F'''BARNSTABLE LOCATION 103 y I • &A SEWAGE#=— VILLAGE W• ASSESSOR'S MAP&PAR L WOE INSTALLER'S NAME&PHONE NO.yC..J��Y�1� • SEPTIC TANK CAPACITY If-uv 3. LEACHING FACILITY: (type) size) Z X i?_•g 7 NO.OF BEDROOMS OWNER PERMIT DATE: 1 IN COMPLIANCE DATE: (p o Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility _Feet Private Water Supply Well and Leaching Facility(If any wells exist on /� site or within 200 feet of leaching facility) 1 �Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY "4w �� 6$ � I WAAI 1937 °'�%'Il ZD� r 7� No. c (i2 Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: 4-Z PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes Applitation for M18t10sal *pstrw Caristruttion permit Application for a Permit to Construct( ) Repair( ) Upgrade( Abandon( ) ❑Complete System t ndividual Components Location Address or Lot No. �gdv7 1*14 i5� _ e ' NAB,Address,and Tel.No. Assessor's Map/Parcel � I"t•i►W �/{ 0 9` � Installer's Name Address and Tel.No. Desi is Name,Addr s and Tel.No. -W c'l�Qi�11�J C®e�/ V671 ilk / / �: VV o Z e" Type of Building: 153 Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.requir d) gpd Design flow provided gpd Plan Date �� � Number of sheets I Revision Date ) Z Title 'Gj Size of Septic Tank W Mw Type of S.A.S. Description of Soil Nature of Repairs of Alteration (Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Bf o e th. Signed Date Application Approved by ' 11,\C Date Application Disapproved by Date for the following reasons Permit No.ao 0 - d f Date Issued • , . ":. _�(l fly,:,.� A .; .y f Entered in computer: THE COMMONWEALTH OF MASSACHUSETTS Yes PUBLIC HEALTH DIVISION' - TOWN OF BARNSTABLE, MASSACHUSETTS 4plitation for M sposal 6pstem Construction 3permit '� Application for a Permit to Construct( ) Repair( ) Upgrade(V) A' bandon( ) ❑Complete System 1�*ndr ividual Components Location Address or Lot No. 10-37 M�41��tt,'' j��� Orwderys i�d�ess,and Tel.No. Assessor's Map/Parcel ZA�/a: u1 IM-1 W Installer's Name Address,and Tel!No. Desi er's Name,Address,and Tel.Nvcr PIAJ r Z .." j Type of Building: a - Dwellirig No.of_Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type ofuilding No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) ,•`• �,�e�✓� gpd Design flow provided �_ 1" gpd Plan Date 11,1 lot 1 1cl Number of sheets Revision Date 'Title Size of Septic Tank �L�1L�1 � { Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) tl � Date last inspected: - Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system/in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of `, Compliance has been issued by this Board of Health. Signed \`� ' n,. ? _ _ Date Application Approved by t(/ , ,-� c v �� - Date I t a Q i Application Disapproved by r Date . for the following reasons Permit No. go )o : ��� Date Issued P w -_-.___. .-.:____.------- ------ ---------------- -_--.--________--_-�-----_--.--- _...----------�_. - _ -_------------------ f THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Comptiante THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(k," Upgraded( ) Abandoned( )by CAID At-- 0Vu4 M-Mv-1 at �!DQTC, 6gv4 has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No` n-o dated 11 /j3� �,..c.. _ Installer C L4� -/' 'v Designer >4 vr,D #bedrooms i Approved design_ow I �„� gpd ��,, r The issuance of this permit shall not be construed as a guarantee that the system wil funetir nf as designed. Date I -------------------- - -- ------------------------- --------_------------------------------------------�------------------------- No. ��"63 - - Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Misposal 6pstem Constrntti0u'vermit Permission is hereby granted to Construct( ) Repair( ) Upgrade( Abandon( ) System located at 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 permit. Date / �,1CJ Approved by / �, I Town of Barnstable Baxrrsrnsr.�. Board of Health 200 Main Street,Hyannis MA 02601 Office: 508-862-4644 John T.Norman FAX: 508-790-6304 Donald A.Guadagnoli,M.D. Paul J.Canniff,D.M.D. January 27, 2020 Mr. David B. Mason, R.S. 28 Powder Hill Road Barnstable, MA 02630 RE 1'837 Allairi,Street (Rt 6A), West'Bariistable MA:ar" A1216 033 � Dear Mr. Mason, You are granted variances on behalf of your clients, Michael and Sara Rabideau, to construct an onsite sewage disposal system at 1837 Main Street (Rt. 6A), West Barnstable, Massachusetts. The variances granted are as follows: Section 397-8(E) of the Town of Barnstable Code: To construct a soil absorption system 103 feet away from an onsite private well, in lieu of the 150 feet minimum separation distance required. Section 397-8(E) of the Town of Barnstable Code: To construct a soil absorption system 101 feet away from a neighbor's well (#1855), in lieu of the 150 feet minimum separation distance required. Section 397-8(E) of the Town of Barnstable Code: To construct a soil absorption system 103 feet away from a neighbor's well (#1857), in lieu of the 150 feet minimum separation distance required. These variances are granted because the physical constraints at the site severely restrict the location of the new soil absorption system due to the groundwater direction flow and the existing locations of private drinking water wells in the area. Sincerel yours, r ohn T. Norman Chairman Q:\WPFILES\MasonRabideau 1837MainStreetWestBarnstable Variance Decision 2020.docx � I I Town of Barnstable Inspectional Services • ,�s,�srttn,e, • Public Health Division KAU 3 0sa Thomas McKean, Director a�� 200 Main Street,Hyannis,MA 02601 Office: 508-8624644 Fax: 508-790-6304 Installer& Designer Certification Form Date: 1 Sewage Permit# Assessor's Map\Parcel Z 1 Designe : Installer: Address: ' `�.r Address: On �' 666T GNA)P&_ U was issued a permit to install a (d te) (installer) septic system at 1g�7 �; W aged on a design drawn by ,n (address) �ti4-�11 - `lam- '�-► dazed t l 1 �1 ZI (designer) renced above was installed substantial) accordin to certify that the septic system referenced Y g the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. Strip out (if required) was inspected and the soils were found satisfactory. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State & Local Regulations. Plan revision or certified as-built by designer to follow. Strip out(if required) was inspected and the soils were found satisfactory. I certify that the system referenced above was constructed in compliance with the to rms of the AA approval letters(if applicable) OF�gss9 II DAVID cy (Install 's Signature MASON N0.1066 r i�TE a ( 1I �% Here)Designer's ignature) (Affix • M ,�- PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. WoaWeptAME4LTHISEWER connecASEPTIADesiper Certification Form Rev 8.14-13.DOC _ THE T Town of Barnstable BARNSrnet.F. MAn 039�- ,�� Board of Health 200 Main Street,Hyannis MA 02601 Office: 508-862-4644 John T.Norman FAX: 508-790-6304 Donald A.Guadagnoli,M.D. Paul J.Canniff,D.M.D. January 27, 2020 Mr. David B. Mason, R.S. 28 Powder Hill Road Barnstable, MA 02630 RE: 1837 Main Street (Rt. 6A), West Barnstable MA A= 216-033 Dear Mr. Mason, You are granted variances on behalf of your clients, Michael and Sara Rabideau, to construct an onsite sewage disposal system at 1837 Main Street (Rt. 6A), West Barnstable, Massachusetts. The variances granted are as follows: Section 397-8(E) of the Town of Barnstable Code: To construct a soil absorption system 103 feet away from an onsite private well, in lieu of the 150 feet minimum separation distance required. Section 397-8(E) of the Town of Barnstable Code: To construct a soil absorption system 101 feet away from a neighbor's well (#1855), in lieu of the 150 feet minimum separation distance required. Section 397-8(E) of the Town of Barnstable Code: To construct a soil absorption system 103 feet away from a neighbor's well (#1857), in lieu of the 150 feet minimum separation distance required. These variances are granted because the physical constraints at the site severely restrict the location of the new soil absorption system due to the groundwater direction flow and the existing locations of private drinking water wells in the area. Sincerely yours, j� ohn T. Norman Chairman Q:\WPFILES\MasonRabideau 1837MainStreetWestBarnstable VarianceDecision202O.docx 3 i �TFI! DATE: `Z711� $95.00 FEE*: p' BARNMEM s Town of Barnstable REC.BY: SCHED.DATE: Board of Health 200 Main Street,Hyannis MA 02601 Office: 508-8624644 -'' Paul J.Canniff,D.M.D. FAX: 508-790-6304 Donald A.Guadagnoli,M.D. Junichi Sawayanag, VARIANCE REQUEST FORM LOCATION L Property Address: Assessor's Map and Parcel Number: Size of Lot: b� � � Wetlands Within 300 Ft. Yes Business Name: No Subdivision Name: APPLICANT'S NAME: e Phone Did the owner of the property authorize you to r 'present him or her? Yes No ��— PROPERTY OWNER'S NAME CONTACT PERSON Name: IPM Name-Dwi r4�6a4, Address: r hQ t , Address: -gyp Phone: Phone: �- EMAIL:jfjbA(A f2MA JE� e f VARIANCE FROM REGULATIONe(ufjg.Code#) REASON FOR VARIANCE(May attach separate sheet if mores ace needed) NATURE OF WORK: House Addition House Renovation LJ Repair of Failed Septic System Checklist (to be completed by office staff-person receiving variance request application) Please submit first four on list as 5 collated packets. A. Five(5)copies of the completed variance request form B. Five(5)copies of MA DEP approval letters for Innovative/Alternative septic system(when proposing an I/A system or secondary treatment unit(S.T.U.). C. Five(5)hard copies of engineered plan submitted(e.g.septic system plans)and one(1)electronic version submitted to email: health@town.barnstable.ma.us D.Five(5)copies of labeled dimensional floor plans submitted(e.g.house plans or restaurant kitchen plans)and one(1)electronic version. A completed seven(7)page checklist confirming review of engineered septic system plan by submitting engineer or R.S. Signed letter stating that the property or business owner authorized you to represent him/her for this request Applicant must notify abutters by certified mail at least ten days prior to meeting date at applicant's expense(for Title V and/or local sewage regulation variances only). Full menu—Five(5)copies of full menu submitted(for grease trap variance requests only). Fee Submitted*$95.00 for the following variances: 1)New construction,2) Septic repairs with increase in flows, and 3)New owner/new lessee applying for food, pool or body art variances. Exemptions from Variance Fee: 1) Septic repair without an increase in flow and variances granted at the counter,2)Monitoring Plans,and 3)Temporary Food(not a"variance"). Variance request submitted at least 15 days prior to meeting date VARIANCE APPROVED Paul J.Canniff,Chairman NOT APPROVED Donald A.Guadagnoli,M.D. C:\Users\decollik\AppData\Local\Microsoft\Windows\INetCache\Content.Outlook\QDLJENHC\VARIREQ Rev APR 4- 2018.docx 1 " OPIP41col cU Certified Mail Fee _ $ $3.50 0630 on Extra ervices&Fees(cneckbox,addree tee 07 o ❑Return Re�pt m�cop» $ E3 ❑Return Receipt(electronic) C �'P Postmark ❑Certified Mail Restricted Delivery^�3 " Here ❑Adult Signature Required � $Adult Signature Restrictedry$ .C $�9e $oSV� N :v T tal Postage and Fees > 12/27/2014 $M� q Sent To s r3 MiRand ------------- Apt.llfo., r x)�fo: 6 pity State f/P+da 4.65 ------------------------- n 'Certified Mail service provides the following benefits: .di A receipt(this portion of the Certified Mail labeg. for an electronic return receipt,see a retail "0 A unique identifn r for your mailpiece. associate for assistance.To receive a duplicate n Elecbotdc verification of delivery or attempted return receipt for no additional fee,present this deliymy, USPSO-postmarked Certified Mail receipt to the A record of delivery(Including the recipients retail associate. signature)that is retained by the Postal Service' Restricted delivery service,which provides for a specified period. delivery to the autliddressee;spertified;by name,or to the addressee'saor'iied agent:` ,important Reminders: Adult signature service,which requires the in You may purchase;Certified Mail service with signee to begat least 21 years of age(not first-Class Mail®,First-Class Package Service®; ,• , available at rataiq. or Priority WHO service. "' ^� I.I!t^tt�Adult signature restricted delivery service,which *Certified Mail service is notavaltable for requires the signee to be at least 21 years of age international mail. (ICi.i i and provides delivery to the addressee specified .,OR insurance coverage Is notavallable for purchase 1);r by name,or to the addressee's authorized agent With Certified Mail service.However,the purchase.. (not available at retail). Of Certlfied Mail service does not change then-i• To ensure that your Certified Mail receipt is"%, tnsurance coverage automaticalty,included with accepted as legal proof of mailing,it should bear a certain Priority Mail items. USPS postmark.If;you would like a postmark on, :■.'For an additional fee,and with a proper this Certified Mail receipt,please present fur endorsemerd do the mailplece,'you may request Certified Mail item.aka Post Office'for the following services: postmarking.0 you don't need a postmark on this Return receipt service,which prmrfdes a record (Certified Mall receipt,detach the barcoded portion of delivery(including the recipierd's signature). of this label,affix it to the mailpiece,apply You can request a hardeopy return receipt or an . .appropriate postage,and deposit the mailpiece. electronic version.For a hardcopy return receipt, complete PS Form 3811,Domestic Return R eelpt attach PS Form 3811 to your mailpiece; IMPORTARIP Save this receipt for your records. ,� Form 3800,April 2015(Reverse)PSN 7530-02-000.9047 1 / a I, Michael Rabideau,give permission to David B. Mason, RS to represent 1837 Main Street,West Barnstable, MA for the variance request before the Barnstable Board of Health. c7i2`l 6 M chael R bideau Date Variance Request for 1837 Main Street, West Barnstable The homeowner is proposing a new septic soil absorption system to replace a failed leaching system that was installed in 1994. The proposed leaching system is in the exact location as the failed system. The system is designed for the existing three (3) bedrooms. There is no proposed increase in bedrooms. Ground water flow is to the North,thus flow from the leaching is flowing away from both wells. All abutting wells are 150'+from the proposed soil absorption system. Variances requested are only for the 1837 Main Street and 1855 Main Street. Variances Requested from; Article III Private Well Protection 397-8E Well Location (e)(f) (e) Requires the Septic Tank to be 100 feet from the well. The existing septic tank for 1837 Main Street is 84 feet from the existing well for 1837 Main Street. A 16'variance is requested. (f) Requires the septic leaching to be 150 feet from the well. The well for 1837 Main Street is 103'from the proposed leaching. A variance of 47' is requested. The well for 1855 Main Street is 101'from the proposed leaching.A variance of 49' is requested. No. -- BOARD OF HEALTH TOWN OF BARNSTABLE DESMOND WELL DRILLING, INC. 5 RAYBER ROAD,BOX ORLEAVS,MA 02653Zippricat ion-for lVerr Confitruct ion Permit (508)240-1000 Application is hereby made for a permit to Construct ( , Alter ( ), or Repair ( )an individual Well at: Location — Address Assessors Map and Parcel -3`-S-&9A--- Owner Address oa Co(o g Installer — Driller Address Type of Building Dwelling ��' -- ° -- Other - Type of Building—= —___—__--____ No. of Persons-- _.-_____ Type of Well 01-'#0 VL— —__—_ Ca acit Ii p-<- 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 ACertificate.o Compliance has been issued by the Board of Health. Signe _ date 9Application Approved By. date Application Disapproved for the following Vasons: — date Permit No. Q� _— Issued�_—-- -— - -- —---—-— -------- date ----------------------- BOARD OF HEALTH TOWN OF BARNSTABLE Certificate Of Compliance THIS IS TO CERTIFY, That the Individual Well Constructed (-)--A*ltered ( ), or Repaired ( ) by -- AAA—I ID fEL -D t—. ---- -----— — -— — ------- __--.—_ 5 RAYBER ROAD,BOX 2783 Installer ORLEANS,MA 02653at tout 10U0--- has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation as described in the application for Well Construction Permit No. ------__—___Dated—____—_-____-___ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE -- _-- _ Inspector-__----------_______.__---------____-- No. --- -- --- Fee-----Z------------- BOARD OF HEALTH TOWN OF BARNSTABLE Zipp[icat ion ArWell Cot 15tructionPermit Application is hereby made for a permit to Construct ( , Alter ( ), or ( Repair )an individual Well at: P Location — Address Assessors Map and Parcel Yl✓t 1C�E{ ,�_ a -t D r� cJ — Ll --s-- - Owner Address Oa Cc�o g -l�.,� ,-2-=4 —C ✓L� __9 a(< Installer — Driller,,' + Address Type of Building Dwelling Other - Type of Building-=--__—__ -__ No. of Persons----- _—__-___- Type of Well Z11 1 00 U(�- Capacity- Purpose of Weld _ ? !-v��(_ 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 Certificate .of Compliance has been issued by the Board of Health. Signe �— date Application Approved By -2 l / date Application`Disapproved for the following /asons: date Permit No. y L —_— Issued---— --------------- =---- date BOARD OF HEALTH TOWN OF BARNSTABLE i C ertif irate Of Compliance THIS IS TO CERTIFY, That the Individual Well Constructed ("tered ( ), or Repaired ( ) by— --- ---------—__—_-_ ----- ----- -- - ------_- installer at L7 has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation as described in the application for Well Construction Permit No. -----------_—___Dated---------------- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE -- —— - - - Inspector--------— --_-__ —_----- ° BOARD OF HEALTH Y. TOWN OF BARNSTABLE ell Conoruct ion Permit No. � V - v � '-• Fee- - Permission is hereby granted _ __— _ ________—_—______--_______________—_ to Construct (- , Alter ( ), or Repair ( ) an Individual Well at: ---- - - ------------------ Street as shown on t e a lication fo a fell Construction Permit Q /02 !J / �//y No.-_._ __ Dated--- __ _ -• -_ - DATE Boar- of Heal h I Massachusetts Department of Environmental Protection L Bureau of Resource Protection! WELL DRILLER Please specify work performed: Address at well location: New Well _ Street Number: Street Name: 1837 IMAINSTREET Please specify well type: Building Lot#: Assessor's Map#: Domestic r 44�— J Assessor's Lot#: ZIP Code: Number Of Wells: 02668 City/Town: Well Location BARNSTABLE In public right-of-way: GPS Yes No North: West: 41.69788 �0.34783 Subdivision/Property/Descriptron: Mailing Address: click here if same as well location address Property Owner: Street Number: Street Name: RABIDEAU 11837 MAIN STREET City/Town: State: Engineering Firm: BARNSTABLE l MASSACHUSETTS {— ZIP Code: 02668 ----- _' Board of health permit obtained: Yes • Not Required Permit Number: Date Issued: W2010016 �8/6/2010 EAUG. 2 7 RECD Page 1 of 1 Massachusetts Department of Environmental Protection 1,7 Bureau of Resource Protection-Well Driller Program `* Well Completion Reports(General) WELL DRILLER - GENERAL WELL FORM - DRILLING METHOD Overburden Bedrock Auger Choose Bedrock- < WELL LOG OVERBURDEN LITHOLOGY From To(ft) Code Color Comment Drop In Extra fast or slow Loss or addition of (ft) drill stem drill rate fluid ROCK AT C 20 �SiltySand Brown • Yes; • Fast • Slow; • Loss • Addition; -- SURFACE - �_.__ f t - SOME SILT --- _ 20 30 Medium Sand Brown C Yes Fast Slow; Loss Addition!, r I I --- ,[-_ 30 50 Fine To Coarse Sand Brown Yes Fast Slow Loss Addition � C �- �50 • 60 Fine To Coarse Sand Brown Yes; Fast Slow Loss Addition j I - - WELL LOG BEDROCK LITHOLOGY Visible Extra 'From Drop in Extra fast or slow Loss or addition of To(ft) Code Comment Rust Large (ft) drill stem drill rate fluid Staining Chips Choose Code Yes' Fast Slow, Loss Addition Yes; Yes (� F- _ �- - ADDITIONAL WELL INFORMATION Developed Yes No! Disinfected Yes No Total Well Depth 60 _ Depth to Bedrock �— Fracture Surface Seal Type None Enhancement Yes No CASING F. Is Casing f From: 1 To: 0 From To Type Thickness> Diameter Driveshoe 0 56 Polyvinyl Chloride Schedule 40 4 Yes; SCREEN No Screen' From To Type Slot Size Diameter 56 60 Stainless Steel Well Point 0.012__ F^ WATER-BEARING ZONES DRY WELL; From To Yield(gpm) 17 60 15 PERMANENT PUMP(IF AVAILABLE) 2 Wire Constant Speed Pump Description Horsepower Submersible 1/2 Page 1 of 2 3 Massachusetts Department of Environmental Protection Bureau of Resource Protection—Well Driller Program Well Completion Reports(General) Pump Intake Depth(ft) 155 _ Nominal Pump Capacity(gpm) �10 ANNULAR SEAL/FILTER PACK From To Material 1 Weight Material 2 Weight Water(gal) Batches Method Of Placement Choose Material Choose Material (�� Choose One-- � �� 1 �- WELL TEST DATA Time Pumping Time To Recovery(ft Date Method Yield(gpm) Level (ft Pumped BGS) - Recover BGS) r ) . 8/1 1120 1 0 ' Constant Rate Pump 15 1.36 20 :01 17 WATER LEVEL Date Measured Static Depth BGS(ft) Flowing Rate(gpm) 8/11/2010 17 15 COMMENTS WELL DRILLERS STATEMENT This well was drilled or altered under my direct supervision,according to the applicable rules and regulations,and this report is complete and accurate to the best of my knowledge. Driller THOMASEDESMONDIII Registration# 764 Supervising Driller Signature DESMONDIII,THOMAS - - Firm I DESMOND WELL DRILLIN Rig Permit# i100 Date Job Complete 8/11/2010 NOTE:Well Completion Reports must be filed by the registered well driller within 30 days of well completion. E Page 2 of 2 fi °f CERTIFICATE OF ANALYSIS Page: 1 �s Barnstable County Health Laboratory Report Prepared For: Report Dated: 8/12/2010 Sally Desmond Order No.: G1059264 Desmond Well Drilling P O Box 2783 Orleans, MA 02653 Laboratory ID#: 1059264-01 Description: Water-Drinking Water Sample#: Sampling Location:\1837 Main Street Barnstable,MA Collected: 8/10/2010 Received: 8/11/2010 Collected by: Customer Routine Tested ITEM RESULT UNITS RL MCL Method# 1.2 mg/L 0.10 10 EPA 300.0 8/11/2010 Nitrate as Nitrogen - ND mg/L 0.10 1.3 SM 3111 B 8/12/2010 Copper mg/L 0.10 .0.3 SM 3111B 8/12/2010 i Iron 0.20 17 mg/L 1.0 20 SM 311113 8/12/2010 Sodium Absent P/A 0 0 SM9223 8/Il/2010 Total Coliform EPA 120.1 8/11/2010 C 6.2 Conductance 150 umohs/cm 2.0 pH pH-units 0 SM 4500 H-6 8/11/2010 Water sample meets the recommended limits for drinking water of all the above tested parameters. Approved By:--- Attached please find the laboratory certified parameter list. (Lab rector) 14 ND None Detected RL = Reporting Limit MCL=Maximum Contaminant Level Superior Court House, PO.Box 427, Barnstable, MA 02630 Ph: 508-375-6605 Page: °F bA°, CERTIFICATE OF ANALYSIS 1 i t >� i0'' �. ._. ' Report For: Barnstable County Health Laboratory t„�,i X s<^' Sally Desmond Report Dated: 8/12/2010 Desmond Well Drilling Order No.: G1059264 P O Box 2783 Orleans, MA 02653 Laboratory ID#: 1059264-01 Description: Water-Drinking Water Sample#: Sampling Location: 1837 Main Street Barnstable,MA Collected: 8/10/2010 Received: 8/11/2010 Collected by: Customer EPA 524.2- Volatile Organics by GUMS ITEM RESULT UNITS RL MCL Method# Analyst Tested Note Dichlorodifluoromethane ND ug/L 0.50 EPA 524.2 yn 8/11/2010 Chloromethane ND ug/L 0.50 EPA 524.2 yn 8/11/2010 Vinyl chloride ND ug/L 0.50 2.0 EPA 524.2 yn 8/11/2010 Bromomethane ND ug/L 0.50 EPA 524.2 yn 8/11/2010 1,1,1,2-Tetrachloroethane ND ug/L 0.50 EPA 524.2 yn 8/11/2010 1,1,1-Trichloroethane ND ug/L 0.50 200 EPA 524.2 yn 8/11/2010 1,1,2,2-Tetrachloroethane ND ug/L 0.50 EPA 524.2 yn 8/11/2010 1,1,2-Trichloroethane ND ug/L 0.50 5.0 EPA 524.2 yn. 8/11/2010 1,1-Dichloroethane ND ug/L 0.50 EPA 524.2 yn 8/11/2010 1,1-Dichloroethene ND ug/L 0.50 7.0 EPA 524.2 yn 8/11/2010 1,1-Dichloropropene ND ug/L 0.50 EPA 524.2 yn 8/11/2010 1,2,3-Trichlorobenzene ND ug/L 0.50 EPA 524.2 yn 8/11/2010 1,2,3-Trichloropropane ND ug/L 0.50 EPA 524.2 yn 8/11/2010 1,2,4-Trichlorobenzene ND ug/L 0.50 70 EPA 524.2 yn 8/11/2010 1,2,4-Trimethylbenzene ND ug/L 0.50 EPA 524.2 yn 8/11/2010 1,2-Dibromo-3-chloropropane " ND ug/L 0.50 EPA 524.2 yn;: 8/la/2010 1,2-Dibromoethane(EDB) ND ug/L 0.50 EPA 524.2 yn 8/1 1120 1 0 1,2-Dichlorobenzene ND ug/L 0.50 600 EPA 524.2 yn 8/11/2010 1,2-Dichloroethane ND ug/L 0.50 5.0 EPA 524.2 yn 8/11/2010 1,2-Dichloropropane ND ug/L 0.50 EPA 524.2 yn 8/11/2010 1,3,5-Trimethylbenzene ND ug/L 0.50 EPA 524.2 yn 8/11/2010 1,3-Dichlorobenzene ND ug/L 0.50 EPA 524.2 yn 8/11/2010 1,3-Dichloropropane ND ug/L 0.50 EPA 524.2 yn 8/11/2010 1,4-Dichlorobenzene ND ug/L 0.50 5.0 EPA 524.2 yn 8/11/2010 2,2-Dichloropropane ND ug/L 0.50 EPA 524.2 yn 8/11/2010 2-Chlorotoluene ND ug/L 0.56 EPA 524.2 yn 8/11/2010 4-Chlorotoluene ND ug/L 0.50 EPA 524.2 yn 8/11/2010 Benzene ND ug/L 0.50 5.0 EPA 524.2 yn 8/11/2010 Bromobenzene ND ug/L 0.50 EPA 524.2 yn 8/11/2010 Bromochloromethane ND ug/L 0.50 EPA 524.2 yn 8/11/2010 Bromodichloromethane ND ug/L 0.50 EPA 524.2 yn 8/11/2010 ug/L 0.50 EPA 524.2 yn 8/11/2010 Bromoform ND Carbon tetrachloride ND ug/L 0.505.0 EPA 524.2 yn 8/11/2010 ND=None Detected RL = Reporting Limit MCL=Maximum Contaminant Level Superior Court House, PO.Box 427, Barnstable, MA 02630 Ph: 508-375-6605 i f RA �;. CERTIFICATE OF ANALYSIS a, Page: 2 in ..; Report For: Barnstable y CountyHealth Laboratory ! Y s r t:, Sall cHu.. Y Desmond Report Dated. 8/12/2010 Desmond Well Drilling Order No.: G1059264 P 0 Box 2783 Orleans, MA 02653 Laboratory ID#: 1059264-01 Description: Water-Drinking Water Sample#: Sampling Location: 1837 Main Street Barnstable,MA Collected: 8/10/2010 Collected by: Customer Received: 8/11/2010 EPA 524.2- Volatile Organics by GUMS ITEM RESULT UNITS RL MCL Method# Analyst Tested Note Chlorobenzene ND ug/L 0.50 100 EPA 524.2 yn 8/11/2010 Chloroethane ND ug/L. 0.50 EPA 524.2 yn 8/11/2010 Chloroform 0.82 ug/L 0.50 80 EPA 524.2 yn 8/11/2010 cis-1,2-Dichloroethene ND ug/L 0.50 70 EPA 524.2 yn 8/11/2010 cis-1,3-Dichloropropene ND ug/L 0.50 EPA 524.2 yn 8/11/2010 Dibromochloromethane ND ug/L 0.50 EPA 524.2 yn 8/11/2010 Dibromomethane ND ug/L 0.50 EPA 524.2 yn 8/11/2010 Ethylbenzene ND ug/L 0.50 700 EPA 524.2 yn 8/11/2010 Hexachlorobutadiene ND ug/L 0.50 EPA 524.2 yn 8/11/2010 Isopropylbenzene ND ug/L 0.50 EPA 524.2 yn 8/11/2010 Methylene chloride ND ug/L 0.50 5.0 EPA 524.2 yn 8/11/2010 Methyl-tert-butyl ether 2.0 ug/L, 0.50 EPA 524.2 yn 8/11/2010 Naphthalene ND pg/L 0.50 EPA 524.2 yn 8/11/2010 n-Butylbenzene ND ug/L 0.50 EPA 524.2 yn 8/11/2010 n-Propylbenzene ND ug/L 0.50 EPA 524.2 yn 8/11/2010 p-Isopropyltoluene ND ug/L 0.50 _.EPA 524.2 Y n - 9/1112010 sec-Butylbenzene ND ug/L 0.50 EPA 524.2 yn 8/11/2010 Styrene ND ug/L 0.50 100 EPA 524.2 yn 8/11/2010 tert-Butyl benzene ND ug/L 0.50 EPA 524.2 yn 8/11/2010 Tetrachloroethene ND ug/L 0.50 5.0 EPA 524.2 yn 8/11/2010 Toluene ND ug/L 0.50 1000 EPA 524.2 yn 8/11/2010 Total xylenes ND ug/L 0.50 10000 EPA 524.2 yn 8/11/2010 trans-1,2-Dichloroethene ND ug/L 0.50 100 EPA 524.2 yn 8/11/2010 trans-1,3-Dichloropropene ND ug/L 0.50 EPA 524.2 yn 8/11/2010 Trichloroethene ND ug/L 0.50 5.0 EPA 524.2 yn 8/11/2010 Trichlorofluoromethane ND ug/L 0.50 EPA 524.2 yn 8/11/2010 Water sample meets the recommended limits for drinking water of all the above tested parameters. Attached please find the laboratory certified parameter list. ' Approved By.-..- _ (L Director)i ND=None Detected RL = Reporting Limit MCL=Maximum Contaminant Level Superior Court House, PO.Box 427, Barnstable, MA 02630 Ph: 508-375-6605 TROY WILLIAMS SEPTIC INSPECTIONS Certified by MA Department of Environmental Protection �/r f (508) 385-1300 19 Hummel Drive ` S�A .47 South Dennis, MA 02660 � Qa o,� OIFIV COMMONWEALTH OF MASSA S ' TS ` EXECUTIVE OFFICE OF ENVIRON FAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION UV ONE WINTER STREET, BOSTON MA 02108 (617) 292-5500 TRUDY CORE Secretary ARGEO PAUL CELLUCCI DAVID B. STRUHS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Mu,h cS�r�c �- C►-oS5 �h Property Address: 1832 Name of Owner Pa,f r � c r C., w. G t+-I^v-s- &6 I,G . Address of Owner: /8 X 7 Date of Inspection: $/.,y/9 9 - s -6 4 /� W Name of Inspector:(Please Print) Trey Williams am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) Company Name: Troy 1M1rilliams Se tRic Inspections Mating Address: 19 Hummel'Drive, So. Dennis. MA 02660 Telephone Number: (508) 385-1300 CERTIFICATION STATEMENT 1 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 inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: I/ Passes Conditionally Passes Needs Further Evaluation By the Local Approving Authority _ Fails / tf ` /ma Inspector as Signature: ��^,uL !/� t�«d Date: y/I1 9 The System Inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within thirty(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 Department of Environmental Protection. The original should be sent to ttm system owner and copies sent to the buyer,if applicable,and the approving authority. NOTES AND COMMENTS Although system meets the minimum requirements set forth by the Massachusetts Department of Environmental Protection,certification is not to be construed as a guarantee of future working condition of system,piping or components. This inspection represents the conditions of the system on the Date of Inspection noted above. revised 91? ,fit, , SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (confinued) Prop"Address' 1837 Main Street, West Barnstable MA owner: Date of Inspection: Patricia Ctossan August 24, 1999 INSPECTION SUMMARY: Check A, B, C, or D: A. SYSTEM PASSES: 1 have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure criteria not evaluated are indicated below. COMMENTS: B. SYSTEM CONDMONALLY PASSES:/r//7 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. Indicate yes,no,or not determined(Y, N, or ND). Describe basis of determination in all instances. If "not determined", explain why not. The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached)indicating that the tank was installed within twenty(20) years prior to the date of the inspection;or the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or.exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four 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� revised 9/2/98 P'�V2of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 1837 Main Street, West Barnstable,MA Owner: Patricia Crossan Date of Inspection: August 24, 1999 C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: /V 14 Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 11 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 THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER.IF ANY)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone 1 of a public water supply well. The system has aseptic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) OTHER rev i F aRc l of I I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) 1837 Main Street, West Barnstable,MA Property Address: Patricia Crossan Owner: August 24, 1999 Date of Inspection: D. SYSTEM FAILS: N/1 You must indicate either 'Yes' or 'No" to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. _ Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 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 Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a 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 I 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen, E. LARGE SYSTEM FAILS: A /A 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: The system serves a facility with a design flow of 10,000 gpd or greater(Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 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) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2)• Please consult the local regional office of the Department for further information. revised 9/2/98 ,,. , SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property address: 1837 Main Street,West Barnstable,MA Owner: Patricia Crossan Date of Inspection: August 24, 1999 Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes, No Pumping information was provided by the owner, occupant, or Board of Health. None of the system components have been pumped-for-art least two weeks and-the system has been•receivingirprmaI flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this / inspection. As built plans have been obtained and examined. Note if they are not available with N/A. Y _ The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow. The site was inspected for signs of breakout. J[ _ All system components, excluding the Soil Absorption System, have been located on the site. _ The septic tank manholes-were uncovered,opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions,depth of liquid,depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: _ Existing information. For example, Plan at B.O.H. .Y _ Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable] 115.302(3)(b)1 The facility owner (and occupants,if different from owner) were.provided with information on the.propermaintanance-of Subsurface Disposal Systems. revised 9/2 Page 5ofII f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Owner: Property Address: w 1837 Main Street,West Barnstable,MA Date of Inspection: Patricia CTOssan RESIDENTIAL: August 24, 1999 FLOW CONDITIONS ( MC- Design flow: 9•P• 0 d./bedroom. � Number of bedrooms(design): Number of bedrooms(actual): 3 Total DESIGN flow 36 Number of current residents: Garbage grinder(yes or no): VU Laundry(separate system) (yes or no):M; If yes, separate inspection required Laundry system inspected (yes or no) Seasonal use(yes or no):-[J Water meter readings,if available(last two year's usage(gpd): 1r'.1 c t j i••(( ��6d i t '<<.. L.; a P< ,L Sump Pump(yes or no): LV Last date of occupancy:-( �P. w44 cAasit > COMMERCIAL/INDUSTRIAL: N14 Type of establishment: Design flow:_ apd (Based on 15.203) Basis of design flow 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: OTHER:(Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of informati n: 11�0 n ,,,,. ,. :., a. � a, G�✓a �o fj l,� b i-v i H K of �wtn Systembumped/as part of inspection.(yes or no)_Vo If yes, volume pumped: gallons Reason for pumping: TYPE OF SYSTEM V_ 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) 1/A Technology etc.Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components,date installed Of known) and source of information: ...I. h j / Sewage odors detected when arriving at the site: (yes or no).VO red 9/2/98 I'd 6(I( I I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(corrtirxied) Property Address:owner: 1837 Main Street,West Barnstable,MA Date of Inspection: Patricia Crossan August 24, 1999 BUILDING SEWER: (Locate on site plan) Depth below grade: Material of construction:Zcast iron J/'40 PVC_other(explain) Distance from private water supply well or suction line A//.a Diameter Comments:(condition of joints, venting, evidence of leakage,etc.) hd'c �,./ ��Ha a (� ✓ a ,� c ci)>uh SEPTIC TANK:_ (locate on site plan) Depth below grade: r Material of construction:-x/Concrete_metal_Fiberglass _Polyethylene_other(explain) If tank is metal,list age Is.age confirmed by Certificate of Compliance_(Yes/No) Dimensions:_ c 1/04 Sludge depth:_ Distance from top of sludge to bottom of outlet tee or baffle:2T' Scum thickness: Distance from top of scum to top of outlet tee or baffle: C r� Distance from bottom of scum to bottom of outlet tee or baffle: How dimensions were determined: .Comments: (recommendation for pumping,condition of inlet and outlet tee or baffles,depth of liquid level in relation to outlet invert, structurat4ntegrity, eviden a of leakage,etc.) C e �i� �,,,,,,t y� r reca S ' AlJ GREASE TRAP fly (locate on site 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 bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) revised 9/2/98 Pa2c7ofII M �- 5 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Prop"Air 1837 Main Street, West Barnstable, MA Date of Inspection: Patricia Crossan August 24, 1999 TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or at time of, inspection) (locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_Fiberglass_Polyethylene_other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm present Alarm level: Alarm in working order: Yes_ No Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches,etc.) DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert: Comments: (note.if level and distribution is equal, evidence of solids"carryover, evidence of leakage into or out of box, etc.)_ PUMP CHAMBER:/V(�f (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.) rev i scn c, /-)/9F F'�CrNof 11 M���'► fTav s-�- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(corr6med) Property Address'owner: 1837 Main Street,West Barnstable,MA Date of Irtspecnon: Patricia Crossan August 24, 1999 SOIL ABSORPTION SYSTEM(SAS): (locate on site plan, if possible; excavation not required, location may be approximated by non-intrusive methods) If not located,explain: Type: leaching pits, number:_ leaching chambers,number:-�Zr+F. (�i'L �i S leaching galleries,number:_ leaching trenches,number, length: leaching fields, number, dimensions: overflow cesspool,number:_ Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulif failure, level of pondingp�soil, condition of vegetation, etc.) c v i a c, o vt d, o i I,I - �f rt 6 r .-0 6(�rYJ s r h CESSPOOLS:Lt/ g (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: Materiels of construction: Indication of groundwater: inflow(cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRfVY: (locate on site plan) Materials of construction: Depth of solids: Dimensions: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) revised 9/2/98 f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM . PART C SYSTEM INFORMATION Property Address: / a J M 4. .. S Owner: Date of Inspection: RESIDENTIAL FLOW CONDMONS : Design flow: //0 g•p•d./bedroom. Number of bedrooms(design):o2 Number of bedrooms(actual): f Total DESIGN flow 2-0 — Number of current residents: Q Garbage grinder(yes or no):-,A/-6 Laundry(separate system) (yes or no):,&O; If yes, separate inspection required Laundry system inspected (yes or no) Seasonal use(yes or no):_O Water meter readings, if available(last two year's usage(gpd): �LS+ Sump Pump(yes or no):�o l/w Last date of occupancy:—CLC-L o-s a ..,., 1 U St csy, /y COMMERCIAL/INDUSTRIAL: Al/A Type of establishment: Design flow:_ apd ( Based on 15.203) Basis of design flow 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: OTHER:(Describe) Lest date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of informatio /Cab SYst m Pump h ,. of inspection: (yes or no)/Vd If yes, volume pumped: gallons Reason for pumping: TYPE 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) 1/A Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components, date installed Of known) and source of information: �L t/ C.".C.".S i Sewage odors detected when arriving at the site: (yes or no) Q SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:owner: 1837 Main Street, West Barnstable, MA Date of kupection: Patricia Crossan August 24, 1999 BUILDING SEWER: (Locate on site plan) Depth below grade: 71 Material of construction:_cast iron_,/40 PVC_other(explain) Distance from private water supply well or suction line N/A Diameter Ille Co ments: (condition of joints, venting, evidence of leakage,etc.) rho} a✓�— LI ter .. _. r SEPTIC TANK:_ (locate on site plan) uu (r / eF /rrst✓S• Depth below grade:7� W r Material of construction:_/concrete_metal_Fiberglass _Polyethylene_other(explain) If tank is metal,list age_ Is.age confirmed by Certificate of Compliance_(Yes/No) Dimensions: Sludge depth: ��77 Distance from top of sludge to bottom of outlet tee or baffle:.0 `8 Scum thickness: ' It Distance from top of scum to top of outlet tee or baffle: L rr Distance from bottom of scum to bottom of outlet tee or baffle: How dimensions were determined: Pi'e f7�- Comments: (recommendation for pumpil ,. ndition of inlet and o et tees or baffles,depth of liquid level in relation to outlet invert,structural-integrity, evidence of leakage,etc.)I-4NJ ar"�w a S . GREASE TRAP: (locate on site plan) Depth below grade:_ Materiel 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 lest pumping: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage,etc.) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Prop"Address:owner. 1837 Main Street, West Barnstable, MA Date of kupertion: Patricia Crossan August24, 1999 TIGHT OR HOLDING TANK*",4 (Tank must be pumped prior to, or at time of, inspection) (locate on site plan) Depth below grade:_ Materiel of construction:_concrete_metal_Fiberglass_Polyethylene_other(explain) Dimensions: Capacity gallons - Design flow: gallons/day Alarm present Alarm level: Alarm in working order:Yes No Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches,etc.) DISTRIBUTION BOX:- (locate on site plan) Depth of liquid level above outlet invert: Comments: (note-if level and distribution is equal, evidence of solids car yover, evidence of leakage into or out of box; etc.) � �rt.i-r�•� c.. ' <' .vim � �e �...� .�h.� . 1 a 4(- t-.0.uA-�Qyt (�.�e.,h .L,(e JiOtin � 4 0. �1 CJ hln Ly S 4 S 4r by -��f PUMP CHAMBER:—&�//9 r S cal�h t Li O N.c o G.+ti c�► 0.7� (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.) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 0 ef: Addre1S' 1837 Main Street, West Barnstable, MA Date of Inspection: Patricia Crossan August 24, 1999/ SOIL ABSORPTION SYSTEM(SAS): Y (locate on site plan, if possible; excavation not required, location may be approximated by non-intrusive methods) If not located, explain: Type. L�, tc leaching pits, number: Oh v 6 X z'C-4 P/ leaching chambers, number:_ leaching galleries,number:_ leaching trenches,number,length: leaching fields, number, dimensions: overflow cesspool,number:_ Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure, level of p nding, dafnp soil, condition of egetation, etc.) t 1 ✓ �lJi L7� ct Cs c� 4- CESSPOOLS:1t/ iq (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(cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: (locate on site plan) Materials of construction: Depth of solids.: Dimensions: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) j �•, �, o I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Prop"Address. Owner: 1837 Main Street,West Barnstable,MA Date of Inspection: Patricia Crossan August 24, 1999 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) D © O FN _,221 GN �c r z _ 3 ,, � � y 7 o o r vK -.2'? 1 ,,t. �'A �ouO G�.1�6ti � /j..)��r✓� � 6� E gyro 1. y1���1�-►��0.-5 I � revised 9/2;9g Page 10 of I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(contirx,ed) Property Address: owner: 1837 Main Street,West Barnstable,MA Date of Inspection: Patricia Crossan August 24, 1999 NRCS Report name Soil Type_ Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep_ ✓ SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to Ground water Please indicate all the methods used to determine High Groundwater Elevation: V Obtained from Design Plans on record V/ Observed Site►Abutting property,observation hole, basement sump etc.) Determined from local conditions Checked with local Board of health Checked FEMA Maps Checked pumping records Checked local excavators,installers Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) iS;�'�w. c j � 6��c r✓z S 7L /��'r,/- c�!c /to.- c 1,, c.g w CA�S �z . cl aKa ,,,lo� t� H� } /o�CkILe-- A, revised 9/2/98 Page ii „r ii Page: 1 CERTIFICATE OF ANALYSIS Barnstable County Health Laboratory Report Dated: 09/08/1999 Report Prepared For: Order Number: G9903503 Kinliin Grover Norton P. 0. Box 156 Barnstable, MA 02630 Laboratory ID#: 9903503-01 Description: Water-Drinking Water Sample k: 03503 Samnline Location: 1837 Route 6A, Barnstable P Collected: O8r31/1999 Collected by. RCapen 216/033 Received: 08/31/1999 Routine I'm RESULT UMS MCL 'Method## Testo LAB:IC Lab Nitrate 5.2 mgf1. 10 EPA300.0 8/31/1999 LAB:Mdals Copper 0.1 mg/1. 1.3 SM 311113 9/z/1999 Iron <0.1 -91L 0.3 SM 31 11B 91V1999 Sodium 27 mg/L 20 SM 311113 9/2/1999 LAB: Microbiology Total Coliform Absent P/A Ahscrd P/A 01/1999 LAB: Physical Chemistry Conductance 230 Umowcra EPA 120.1 8/31/1999 pH 5.4 pJA-units EPA 150.1 m i/1999 !vote: The water sample has higher than average levels of Nitrates. Futurc monitoring is recommended(2-3 times per year)to establish any upward trends. Persons on low sodium diet may wish to consult physician due to higher than average result. Approved By. (Ub Direowt) Superior Court(louse, PO. Box 427, Barnstable, MA 02630 Ph:508-375-6605 TOTAL P.©2 r TROY WILLIAMS SEPTIC INSPECTIONS d Certified by MA Department of Environmental Protection (50 85-1300 19 Hummel Drive 110", a 199� South Dennis, MA 02660 ��ly4 pll* fir, COMMONWEALTH OF N4A' sSACHUSETTS u 1 EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS O Fly DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE HINTER STREET. BOSTON, MA 02108 6I7.292-5500 UV_ WILLIAM F.WELD Govemor TRUDY CORE Secretary ARGEO PAUL CELLUCCI Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM DAVICo.mRoner / (� PART A r"pS1N ' "10ERTIFICATION Property Address: 3 7 M o ' 1J. tg.-.s h-S 4 7/la Ig? Address of Owner: P Date of Inspection: c f-cvL G I/en✓o vt . Name of Inspector: Troy Williams (If different) I.T37 Q 7-6.9 1 am a DEP approved srtem inspector pursuant to Section 1S.340 of Title 5 (310 CMR 15.000) w- /9 -✓-s'+. Company Name: Troy .Will iam5 Septic Inspections Mailing Address: 19 Hummel Driype South DpnniS MA 02660 v�66y Telephone Number: _ (5()�Q 5-13 0 D ' CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: Passes _ Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority _ Fail ' Inspector's Signature: items (/-�J`JCt�►w Date: 7 The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(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 Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: A] SYSTEM PASSES: VI have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: B] SYSTEM CONDITIONALLY PASSES: All,9 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. Indicate yes, no,or not determined (Y, N,or ND). Describe basis of determination in all instances. If"not determined",explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached) indicating that the tank was installed within twenty(20)years prior to the date of the inspection; or the septic tank,whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration,or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 04/25/97) Page 1 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A , CERTIFICATION (continued) Property Address: � 9 3 7 114 a-,h S4. Owner: ev e-✓ 00� , Date of Inspection: ,7 It a /`l 7 B) SYSTEM CONDITIONALLY PASSES (continued) /{//W Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). Describe observations: broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four 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 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 the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) OTHER (revised 04/25/97) Page 2 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:/ 3 Owner. Date of Inspection: I-LV e in r 7 J/a �5 DJ SYSTEM FAILS: n/Ijg You must indicate ei;!.er "Yes" or "No" as to each of the following: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage into facility or system component due to an 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 112.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 Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a 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 I 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: 411-9 You must indicate either "Yes" or "No" as to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 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) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 04/25/97) Page 3 of 10 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B (/ CHECKLIST Property Address: / b 3 Owner: L��c✓o h i Date of Inspection: Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes, No Pumping information was provided by the owner, occupant, or Board of Health. _ None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates, during that period. Large volumes of water have not been introduced into the system recently or / as part of this inspection. As built plans have been obtained and examined. Note if they are not available with N/A. +✓ _ The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow. ✓ _ The site was inspected for signs of breakout. _ All system components, excluding the Soil Absorption System, have been located on the site. _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material-of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub-Surface Disposal System. _ Existing information. Ex. Plan at B.O.H. Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) [15.302(3)(b)] (revised 04/25/97) Page 4 of 10 o- e-- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C r�1 C SYSTEM INFORMATION Property Address: g ✓ �-( G" �` J �' Owner: e-v Date of Inspection: -2 / FLOW CONDITIONS RESIDENTIAL: Design flow:,J3 o g.p.d./bedroom for S.A.S. Number of bedrooms: 3 Number of current residents: Garbage grinder (yes or no): ND Laundry connected to system (yes or no): yam%S Seasonal use (yes or no): No Water meter readings, if available Uast two (2) year usage (gpd): 4— Ld. !? Sump Pump (yes or no):-6�-o Last date of occupancy: 6- ,`.� d COMMERCIAUINDUSTRIAL: Type of establishment: Design flow: gallons/day Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)_ Non-sanitary waste discharged to the Title S system: (yes or no)_ Water meter readings, if available. Last date of occupancy: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: �f J 44, (/( • f1 / f' !4/ L? r Il o N. G_ U u✓✓�Gt� , System pumped as part of inspection. (yes or no)_NO If yes, volume pumped: gallons Reason for pumping: TYPE QF 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) I/A Technology etc. Copy of up to date contract? Other APPROXIMATE AGE of all omponents, date installed (if known) and source of information: s �y/f t �/ _2 --JQ:fL� 3.- 4DJ: I-k Sewage odors detected when arriving at the site: (yes or no)zvb (revised 04/25/97) Page S of 10 1" t SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: / Y 3 Owner: L GJ[✓o6,,, Date of Inspection: ., //, � � 7 BUILDING SEWER: N /,-g (Locate on site plan) Depth below grade: Material of construction: _cast iron _40 PVC _ other (explain) Distance from private water supply well or suction line Diameter Comments: (condition of joints, venting, evidence of leakage, etc.) SEPTIC TANK:, (locate on site plan) Depth below grade: / Material of construction: -y—'concrete _metal _Fiberglass _Polyethylene —other(explain) If tank is metal, list age _ Is age confirmed by Certificate of Compliance _(Yes/No) Dimensions:_ v Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: /V0,,VE Distance from top of scum to top of outlet tee or baffle: /` O S cr d-- Distance from bottom of scum to bottom of outlet tee or baffle: A/o S L✓� How dimensions were determined: /0oy S -r- Comments: (recommendation for pumping, condition inlet and outlet tees or baffles, depth of liquid level in relation t outlet invert, structural integrity evidence of leakage, etc.) /Rt5 W ��-c �a,��d ,,, �✓t1 l.� c� c/r t✓ �/n 3 /S N S A— lC.4.J1 y S -t d y �mot.N'► � (i�- /-v-• KJ,.e. S lie u � i l.. � t t c� O f GREASE TRAP: A//,-9 (locate on site 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 bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) (revised 04/25/97) Page 6 of 10 114 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C ? /� [ SYSTEM INFORMATION (continued) Property Address: / ✓ 7 / "` " �^ JA Owner: Le—U Date of Inspection: -2 /f-k TIGHT OR HOLDING TANK: /I (Tank must be pumped prior to, or at time, of inspection) (locate on site plan) Depth below grade: Material of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm level: Alarm in working order _ Yes; _ No Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX:_✓ (locate on site plan) Depth of liquid level above outlet invert: 1 GJ Comments: (note if level an'"istribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.)_ --X? 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.) (revised 0{/2S/97) Page 7 of 10 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C / SYSTEM INFORMATION (continued) Property Address: ( �5 3 C� A Owner. e Ll 61'`.>Ll . Date of Inspection: ..? //a /y SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type. leaching pits, number:_ leaching chambers, number , leaching galleries, number: t leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Alternative system: Name of Technology: Comments: (note condition of soil, signs of hyydddr�auliic failure, level of ponding, conditio of vegetation, etc.) ^ ' r C_OT01^ CESSPOOLS: _AIM (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(cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: /Y (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.) (revised 04/25/97) Page 8 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C t/ SYSTEM INFORMATION Property Address: 0 3 7 /44 1" `� S Owner: L Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow: t t O g.p.d./bedroom for S.A.S. Number of bedrooms: I Number of current residents: U Garbage grinder (yes or no):_l(U Laundry connected to system (yes or no):yC S Seasonal use (yes or no):-/6 Water meter readings, if available (last two (2) year usage (gpd): _ P,- l( Sump Pump (yes or no): A14 Last date of occupancy: ��-� 3 • `"^ n U S COMMERCIAUINDUSTRIAL: /A///g Type of establishment: Design flow:_gallons/day 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: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPIAN/4 RECORDS and source of information: System pumped as pan of inspection: (yes or no) If yes, volume pumped: gallons Reason for pumping: TYPE fDF 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) I/A Technology etc. Copy of up to date contracts' Other APPROXIMATE AGE of all co ponents, date installed (if known) and source of information.' " Sewage odors detected when arriving at the site: (yes or no) D (revised 04/25/97) Page 5 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C g ,I,s SYSTEM INFORMATION (continued) Property Address: 183 3 2 .ice I v. S f Owner: Date of Inspection: 11 1—IJ G�L-,t I BUILDING SEWER: (Locate on site plan) Depth below grade: Material of construction: _cast iron _40 PVC _other (explain) Distance from private water supply well or suction line Diameter Comments: (condition of joints, venting, evidence of leakage, etc.) SEPTIC TANK:, (locate on site plan) Depth below grader v- S y 4) s e•✓ S. Material of construction: -,/-Concrete _metal _Fiberglass _Polyethylene _other(explain) If tank is metal, list age _ Is age confirmed by Certificate of Compliance —(Yes/No) Dimensions: :5 X -i h Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: o?'' Distance from top of scum to top of outlet tee or baffle: 4� Distance from bottom of scum to bottom of outlet tee or baffle: 1� �� How dimensions were determined: Comments: (recommendation for pumping, condition inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, ettc.) / e 4e "s w c,r �,., ` ,��,� o✓�e� �� S u , S 4 t o L) ✓t �s�t S v. GREASE TRAP: N(A (locate on site 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 bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) (revised 04/25/97) Page 6 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: L ✓ �� Date of Inspection: TIGHT OR HOLDING TANK:/y/(Tank must be pumped prior to, or at time, of inspection) (locate on site plan) Depth below grade: Material of construction: _concrete _metal _Fiberglass _Polyethylene —other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm level: Alarm in working order _Yes; _ No Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX:, (locate on site plan) Depth of liquid level above outlet invert: IG y c Comments: (note if level and istributio is ual, evidence of solids carryover, evidence of leakage into or out of box, etc.) ✓ r c PUMP CHAMBER: Al�'9 (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.) (revised 04/25/97) Page 7 of 10 Q � SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C �/ ^� SYSTEM INFORMATION (continued) Property Address: /i O J 7 N( �— •••� S . Owner: L eV G✓o L--, j Date of Inspection: 7 / / /-� SOIL ABSORPTION SYSTEM (SAS):_z (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: , leaching pits, number: Gk c C k6 Z -e_c leaching chambers, number:_ leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Alternative system: Name of Technology: Comments: (note con ition of soil,signs of hydraulic failure, level of ponding, condition of vegetation, etc.) CESSPOOLS: •A/( (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 (cesspool must be pumped as part of inspection) 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.) (revised 04/25/97) Page 8 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C C SYSTEM INFORMATION (continued) Property Address: / a, ? 144 62, S-74 ( w S t� Owner: G ve✓d Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) will 'r 1604- "�w•ti 55 s'6 l \e,o�j '" IZ' (revised 04/25/97) Page 9 of 10 Y � SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: I 3 / 4 G Owner: �e�L�� Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) aa � sy 3N �25 �T. ,/� l G 1k61,4 2 `srsA, e- (revised 04/25/97) Pay 9 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C I SYSTEM INFORMATION (continued) Property Address: l�3 7 41 C' Owner: Date of Inspection: Depth to Groundwater Feet adjusted high uoundwatcr level Please indicate all the methods used to determine High Groundwater Elevation: ZObtained from Design Plans on record Observation of Site (Abutting property, observation hole, basement sump etc.) Determine it from local conditions Check with local Board of health Check FEMA Maps Check pumping records Check local excavators, installers Use USGS Data Describe in your own words how you established the //High Groundwater Elevation. (Must be completed) a - ' (revised 04/25/97) Page 10 of 10 TOWN OF BARNSTABLE LOCATION 7 SEWAGE # -� VILLAf;E ASSESSOR'S MAP & LOT;?/h/- 4 3 INSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY:(type) — (size) NO. OF BEDROOMS 1,5 PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: � � VARIANCE GRANTED: Yes No 1/' ,r w t` TOWN OF BcARNSTABLE sp LG`C"ATION SEWAGE # VILLAGE ASSESSOR'S MAP & LOT IN NAME&PHONE NO. K t J Z SEPTIC TANK CAPACITY /'0 LEACHING FACILITY: (type) (size) 2 'vaa. NO.OF BEDROOMS 3 . ff BUILDER OR OWNER L•cv<-r' PERMITDATE: 'I/2 /2 ;�, COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by '-1—m • f f 1 , IL A / 0 71 APPROVED THE COMMONWEALTH OF MASSACHUSETTS _ ® ns o BOARD OF HEALTH ./j 7 OWN OF BARNSTABLE Dwo ArprV r- at for Diripagal Wurk,i Tomitrnr#iun remit Application is hereby rude for a Permit to C-ortstruct ( ) or Repair ( ) an Individual Sewage Disposal System at• 'fA ocation-Address, or Lot No. �rner - a ' '._. __..... - - ---------------------------------- ------ n- _. �_ nstaller Address eet U Type Building Expansion Attic Size Lot----------- -------------Sq.(f Grinder Dwelling—No. of Bedrooms........ •.--__-----.- No. of ersons_____________________(..___)Showers GarbageCafeteria a Other—Type of Building ___1��� p ( ) ( ) 04 Other fixtures --------------------------------------------------•--- W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length________________ Width---------------- Diameter----_-.......... Depth................ x Disposal Trench—No. .................... Width-------------------- Total Length.................... Total leaching area....................sq. ft. 3 Seepage Pit No_____________________ Diameter-------------------- Depth below inlet.................... Total leaching area..................sq. ft. ,z Other Distribution box ( ) Dosing tank ( ) 0.4 Percolation Test Results Performed by_________________________________________________________________________ Date........................................ ..4 Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Gi, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ O- Description of Soil--•-•-•_...- = v_. - - - � � - -- - - - V ............................................. -•••-••-••••-•--••-•-•-•--•----••••-••-•-••-••••••----•---•-•-•---•__...-•-•-•-•---••••----•-...--•--•-•- ................................................ ... ---•----------------------------•-------•--._.---------•------------=-----.....____...- U Nature of Repairs or Alterations—Answer when applicable._ ' ----f01,1�". 7 " Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliant has been 'ssued by th4boa d of health. Signe _ -/f' 5 .. re Application Approved By .....- --- .-! ... - ---..-.-. .::.. .................. .. .............................................................'------.....-........ Dace Application Disapproved for the following rea.ron.r: ................................................................................... .............................................. ......................... .............................. ... ... . q ...:......... ..... -......-..............................-..............--.................-...-...... .. ........................................ Permit No. _� ... f.:.l` ................. Issued ------------ Dace THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 1 TOWN OF BARNSTABLE, Appliration for Dili-pasal Wnrkii Tomitrurtinn rrrntit Application is hereby made for a Permit to Construct ( ) or Repair ( . ) an Individual Sewage Disposal System at: �' 'Za - . -- Locatim •:\ddress, or Lot No. I ..................................... .................................................... ......... ....- ......... ... tcncr Ad rc ................ ._.. {� � nstalfer Address Type(ef Building !/ Size Lot.................... .....Sq. feet U Dwelling—No. of Bedrooms..........5..--_---.--- ------_.-Expansion Attic ( ) Garbage Grinder ( ) . a Other—Type of Building 1�I��-------. No. of persons---------------------------- Showers ( ) — Cafeteria ( ) dOther fixtures --------------•-------------...--------------------------••---------------•-------........_...------••-•••••-••-•-•••••-•--••...•••-•..........--•--- W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity......_....gallons Length---------------- Width---------------- Diameter................ Depth................ x Disposal Trench--No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. 3 Seepage Pit No------------- ------ Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) '~ Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ (z, Test Pit No. 2................minutes per inch Depth of Test Pit--.................. Depth to ground water........................ <. ••---/--�-------,- .......-•..... ...'-•••-••- ODescription of Soil...........7 .lr/. ....:......:5.......----mil ..__ ---------------------•------•-•----•-- .......................... ----------•--------------'------------------------------------------------------�-- �.y..��- � U Nature of Repairs or Alterations—Answer when applicable..��A �.----Z'V7 A,�-....!' 4 .........••---......•-•..............................••...•...--•......................•..............................------......•----•......•..•............................•......................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental 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 ...............1 . _ .............................. - .-.-.................... _�7�."-.a..5.."....�� l�'C/% Dace Approved By ...........fi ... .---------_----------------- Application ..j ` `.'r y5' Date Application Disapproved for the following reason : -- - ............................ ... . ................................................................. ........ . ................................................... ... . ........................... ... ................................................... .... ... . .... ........................................ Permit No. ...`E/' + --.�l--: .._...._.....-. Issued �?. ../ .. ..... _. Dace II THE COMMONWEALTH OF MASSACHUSETTS BOARD 0 IF HEALTH TOWN OF BARNSTABLE TPrtifirate of Tomplianre THIS IS TO CERTIF-Y,„That the Individual Sewage Disposal System constructed ( ) or Repaired by ............................... -- ..--..._...._... ....- at -----44`- .`T ._/�. � . .. .............. .. ....--.............. has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in _ the application for Disposal Works Construction Permit No. - ------ dated THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED S A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE--.......... .` ... •--...._ - ............ Inspect r.--* -.- ....:........ - ��. '/..-- ....-_...... _--_._-___-___---_,_-.-__----.-_____,-_-_--,__------,_----_-_.---____-._____-----� THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH I� s TOWN OF BARNSTABLE No.....;... FEE..._.... frz� 11iopnsal Workv Tomitrudion Permit Permission is hereby granted------5' ...e? "� � / f', ...................................................... to Construct ('.j or Repair ( ) an Individuaal�Sew�e Disposal Syst street �-7 as shown on the application for Disposal Works Construction Pe mi No._.. �__�. ated----��..�?�..".., s` ,p -------- ----- Board of Health DATE........�``....... ----...- FORM 36508 HOBBS R WARREN.INC..PUBLISHERS t ,/"TOWN OF BARNSTABLE LOCATION l X —3 /"[ SEWAGE # 6 6 3 VIL-I,,XGE /AASSSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. ✓ ,-L SEPTIC TANK CAPACITY Uy LEACHING FACILITY: (type) ��� (size) vZ (S 2- NO.OF BEDROOMS I BUILDER OR OWNER L e.J `a PERMTTDATE: 3� 6 COMPLIANCE DATE: I1 Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) f Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by 7'2p 6,J t i °-S 2 3`I J LOCATION ; SEWAGE PERMIT NO. _ n+ VILLAGE INSIALLER'S NAME i ADDRESS Y,r, /, B U I L D E R OR OWNER �--�_ -re r G! 1, T' DATE PERMIT ISSUED DATE COMPLIANCE ISSUED lit J C /� ' Ky r� . � ` _ �� .� � �� ♦ -� / /p � lll���tttrrr"""111 /• ,/�1/ ........... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...................... .. ................OF......................................................................................... Appliration for Elispaiial Murks Tonstrnrtion rumit Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal System at: .... .7... fly---:S-.n�_�T G✓es. �ucKV.4 6�� - -..... ................ Location Address. or Lot No... o. .. �,. .-lea-®�v 1 .... . 1.�5' .............................................. A, S �` �: �.� ,�,eSnr���e ,..- .... ........-----............. !a I D /� Owner .......Address � & ,27ner 4r:�...............------...--------------•---...._ .......-._...---•--................ Installer Address Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms....... .._..Expansion Attic Garbage Grinder fVp) a`4 Other—T e of Building ��*a No. of persons............................ Showers ( ) YP g --------------- ----------- P --(----)------.Cafeteria dOth fixt es -------------------------------------------------------•------------------------------------------------ LT1 Design Flow........ 2.. .......................gallons per person per day. Total daily flow_.._...-.......��......................gallons. WSeptic Tank—Liquid capacity/040&.gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No.........62.... Diameter......-Ca..... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box �� Dosing tank ( ) Percolation Test Result Performed by.......................................................................... Date........................................ Test Pit No. 1...... minutes per inch Depth of Test Pit.................... Depth to ground water........................ (i Test Pit No. 2................minutes per inch Depth of Test Pit........-.-.-....... Depth to ground water........................ a ----------------------------------•-----...-----..........-•-------•----•---•---•-----------................................................................ 0 Description of Soil.........:..:.:.:—:_..................................•.............................................................................................................. x V .........-•-------------•--•-----......---•-----••--•.....------•---•--- ---....--------•---••---------...------------------------•------------------•-------------------.....-•---------------•--•--•. W U Nature of Repairs or Alterations—Answer when applicab e_ __0._'. .....�____ 5 .--.- .._ U c.JU.----=-� ------ ----- Agreement: The undersigned agrees to install the aforede -bed Individual Sewage Disposal System.in accordance with the provisions of iI'IU 5 of the State San; ry ode Th undersi ed urther agrees not to place the system in operation until as Cer�%� Co b i d t bo d of •ealth. Y V D e - Application Approved By..................... ---. --�... •----•-------•-•--...........----............... ----::::..... vim' ��........--- -------- Date Application Disapproved for the following reasons--------------------------------------------------------------------------------•---•------------....-----.-•••- --.........-•---------------------••-----•-•----------•-------•--•--•----..._.........-.....--••----•--•---------------.....-----...-----....----••--------------•---•---------------------------••-•-•- Date Permit No....----- ---------------- -- Issued_....................................................... Date 3261 Main Street Route 6A Barnstable Village MA 02630 BED OSC 06/12/86 Barnstable Board of Health Town Hall 367 Main Street 617 362 8133 Hyannis, MA 02601 Re: Septic System Construction 1837 Main Street - Route 6A West Barnstable, MA 03-1639.00 Members of The Board: This letter is to inform you that the septic system at the above referenced location has been constructed in substantial compliance with the plan. One minor change did occur. The leach pit was placed where the reserve was proposed. Both the proposed original pit location (now the reserve area) and -the proposed reserve were located 100 feet away from all known wells. If you have any questions or comments, please do not hesitate to contact our office. Very truly yours, BSC/CAPE COD SURVEY CONSULTANTS oe Engineers Stephen A. Wilson, PE Surveyors Project Manager Scientists cc: P. Leveroni Nab Deft Architects D il D SAW/mg Tam Landscape 2SAW24 Architects Planners AI ,ivvv Cape Cod Survey Consultants No. Cr...� Fps...................._........ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...................... ....................OF................... Appliration for Disposal Works Tonstrurtion Truitt Application is hereby made for a Permit to Construct ( ' ) or Repair ( ) an Individual Sewage Disposal System at: / �-- i 7✓ ................_........�.......... .... -----Address ... - - ..._....... ... ....................... Location-Address• or Lot No. S r -.l . L r.:e r v ti � /�'3 7 7 /,i/. ...................... •-�----...---•..._.............._......--------•- ....................-............................................................................. } Owner Address /v.............� -L-----•-..........----•-...._..............--•-••-•-•-- --•..........------....-•-......•---•----••-•-•-•--•-••-----•-----•-..............._........_..... / Installer Address Type ofBuilding ._ Size Lot............................Sq. feet DwellingNo. of Bedrooms___ .....Ex Expansion Attic `� 'U3 — ::. P ( / ) Garbage Grinder ( ) a Other—T ype of Building ....... ....... ....... No. of persons......_..................... Showers ( ) — Cafeteria ( ) �'�''..'` Other, fixtures ------------------------•-----------....--------....----•••--•--•-•••-----•-•-......--------•-•-•......._: Z j } t ' ....gallons. W Design Flow..................................�O�..gallons per person per day. Total daily flow................_.........__....._._... gal WSeptic Tank—Liquid capacityZ.........gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..........� ... Diameter........� .... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box Dosing tank ( ) aPercolation Test Results// Performed by.......................................................................... Date........................................ Test Pit No. I........Y----minutes per inch Depth of Test Pit.................... Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ �+ .--•------••------•-•-•-•-••--•----•----....-•-•-------•••-•-----•...:--•--•---•----------------------------------•--•-•---------.......... ---- 0 Description of Soil.........................................................--.......................-............................................................. U -----•---•-•-••--•--•...........-•----•----•--•-•..............•--......-•-------••------...•-•--•••---------•--------.......:,_.....•---•--•------•••-........----•------•.....-----••--------•- U Nature of Repairs-or.Alterations--Answer when applicable:-..'......................•.._...._.___.._..:_.___....._._. ti ''- f ------...._. ....... Agreement: The undersigned agrees to install the aforedeserrbed Individual Sewage Disposal System in accordance with the provisions of TITLE 11 5 of the State Sanitary/EC/''ode 1 The.tinders fined further agrees not to place the system in operation until a Certificate of Co _ h ,box- of_health.- mp�nSs id� Signed,:: ........--^.................................... ..-•.•-------.......... t' i e� ✓Date,l ApplicationApproved BY............-----••.-• ----.....•---......._.....-------------------••-......_.......----•- -/ - ----- ----------- -------•------- .---•.....................................0.............................Date Application Disapproved for the following reasons:..................................... _ ............. .......................................................--................................................................................................................................. Date PermitNo.......... ................................... Issued-....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ................ 5`"� �� '. O F............. �'......................... Tntifiratr of Toutpliaitrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( or Repaired ( ) by ---- --- --•-- = ..---- r l 1 U J — .Installer at................•----••--••--------•--................--------•-.----- ' , -------- ---------•----------------....------•••---••--•-------•--...-•-----•••-...-•----......---••---•-••--------.... has been installed in accordance with the provisions of TITS 5rof_The State Sanitary Code as dered in the application for Disposal Works Construction Permit No..._...`.............................. dated-_-.-_� l,�- C� THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATI FACTORY. � DATE.......................... ............................................. Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD F,HEALTH OF..................••--••••....... �= No............. ........... F> ...r - ........ Disposal Works Tonufrnrtion Permit Permission is hereby granted f' -- -1---------------------•------•--------------------------- -------------- -.---......... Ind ................................ to Construct ( .)�orrRepai ( ) an ividual Sewage Disposal System ii �� LC1 at No Street / as shown on the application for Disposal Works Construction Permit No... Dated.........�_..7''� �1'............ C ti �"� '4'�---------•---- Board of Health DATE :_ . FORM 12S5 nA.M. SULKI N, INC., BOSTON wh :�l . , ►"�= �.___.____.__. _____.--- .__ASSESSORS MAP : 4Z _____. TEST.HOLE LOGS 1) The installation shall comply with the State Environmental Cade Title v and Town of �'tyf '� PARCEL: Z-4 Hoard of Health Regulations. .�--- SG l L EVALUATOR: �+ ���y� 2) The septic system as proposed on this plan shall not be installed until a licensed town installer t , — FLOOD ZONE; .__-,,C�� ytl TNESS ; a receives approval and an installation permit from the applicable town. REFERENCE* �" ' �'f. / �' , DATE: — 3) Prior to installation,the installer shall verify the location of utilities,sewer inverts,sewer lines i r PERCOLAT I ON RATE:,�. 7Et ��si_ Tr���,��� ` ..► and existing septic components prior to installation. C _L - � 'f 'I�+ 4) Ali gravity sewer piping is to be 4 inch schedule 40 PVC at 1/8"per foot. The first 2 feet out of �- the distribution box shall he level. All piping connections to be glued. TIC p g 5) This septic desi n tan is not to be utilized for property ' P p party line determination or for any other i purpose other then the ro osed septic stem installation. _ .' p p p d� ,�-"'----�. "°� _ _ .«.�. .,..,_ „�,,� '—�'--•—, ' ",�` , 0 �. G) Ali Title V components are to meet'Title V specifications, i ie i 7 Parking shall be prohibited over Title V components unless components are H2O loaded. I C�c.�/`® ( 8) The existing leaching or cesspools shall be pumped and filled with material per Title V LOCATION MAP - _ .. _ .'� ��' . _.._/t�' _ r. �. i�sl>� ��" {{ ' abandonment procedures. Leaching and cesspool(s) and contaminated soils within the i proposed SAS shall be removed and replaced with clean sand per Title V specifications. � r w 9) Septic components are to be 10'from a water service line.Sewer lines crossing a water line shall be sleeved with an appropriately sized schedule 40 PVC with ends grouted. The water service . , line or the septic line can be sleeved with the sleeve being a distance of 10' on both sides of , crossing the line: _ ` 1 ,_� ? � f (ttlF -' 20 If a garbage ender exists in the structure,it is to be removed if the septic s stern is not designed to accommodate a garbage grinder, 11) The installer is responsible for care of excavation around all utilities on the property and SEPT I SYSTEM E S I IN protecting the structural integrity of all structures during the installation process of the septic a FLOW system. i W ESTIMATE 12)This plan only represents that a septic system can be Installed on the property meeting Title V k % , requirements. 1 +BEDROOMS ATAl-/ `/ E131fl ; GALIAY 13) The property owner shall review design criteria to approve the total number of bedrooms and design flow.installation of the septic system as proposed and receipt of payment for the design SEPTIC: TANK - shall be deemed approval of the design criteria by the property owner or agent of. l� ��jj ,t./tAY x e DAYSA�. 14) The validity of this plan shall expire with the expiration of the town installation permit issued for `a2 this plan or the validity of this plan shall expire on the expiration of the Certificate of Compliance vsE I GALLON SEPTIC TANK I . .� WIL' issued for the installation of the proposed system on this plan, A-B'$O"RP`i] S�'STE77,1 U bc_..4 H )C? 500 0v� bttwel BOTTOM AREA: 1� ° Y4 C7,`f 1,11 ` ' m SEPT'11 SYSTEM SECTION �� � t' ) 1, ill ' . j UY _....._ o -i1�� I I I u . 134 GAL SEPTIC TAIL V��'��/r� Q / .�, ' 1t} ��` tt, t ", �. . . n ,a l a ' , ? t a OF / l/� �' DAJID -.._ B. .a.=:.........,r- iV 1 110 fir' S TE AND SEWAGE PLAN R 1 4 Ws 4 ' v !!!^^^i w� .►'' / t L„ � P R PARED FOR : A0 SCALE " 'Y p p \ ✓� /R DRC N Rs IMENTXL DESIGNS • y „ r /t t < { .may .. "'^_•,..-...,-,.. --.,...._ - «.....A.r+...+..+r...+...-�....�..+ ..w..*"..� _ BATE HEALTH AGENT —��_ � sHnvrwa�rrrwaer..ee�wn - �r+ass-.a�•wsr-.•a,...:. ASSESSORS MAP : �� TEST HOLE LOGS -, } comply � The installation shall com I with the State Environmental Code Title V and Town of „ � PARCEL : .__. t Board of Health Regulations.... : ,, _ � SOIL EVALUATOR :_?�` � � _ p system as proposed an this plan shall not be installed until a licensed town installer FLOOD ZONE: �C�% pp WITNESS : �"sVt Ib . 2 e septic ste S receives approval and an installation permit from the applicable town. REFERENCE . d>E'f',Q BATE;�r� 3) Prior to installation,the installer shall verify the location of utilities,sewer inverts,sewer lines '' /Zv , PERCOLATION RATE: and existing septic components prior to installation. - ¢ ON �11 � }� '�, � 4) All gravity sewer piping is to be 4 inch schedule 40 PVC at 1/8"per foot. The first 2 feet out of It Ve / ...�__.. o �. 7 _... r P p g 7H- i TN-2 the distribution box shall be level. Ali piping connections to be glued. �, - 1_ /L- fi l i E✓t? Ln 5) This septic design plan is not to be utilized for property line determination or for any other } + purpose other than the proposed septic system installation. ��' `° - •- � ,�/ '�' ''� 6) All Title V components are to meet Title V specifications. �' � t0ho 7) Parking shall be prohibited over Title V components unless c,mponents are H2O loaded. LOCATION MAP x�' f � r cesspools shah be pumped and filled with material per Title V �' (� JC'� � ~' C�-�y i�lp-{ ��� ��''�P?1pe I-bl°cwt 8) The existing leaching o 11x t{ 07 Jtot7c,o �/1 l` G6 abandonment rocedures. Leaching and cesspool(s)and contaminated soils within the I d I _ ,n proposed SAS shall be removed and replaced with clean sand per Title V specifications. 60 �14 9) Septic components are to be 10'from a water service line.Sewer lines crossing a water line shall be sleeved with an appropriately sized schedule 40 PVC with ends grouted. The wafer service line or the septa line can be sleeved with the sleeve being a distance of 10'on both sides of crossing the line". 10) If a garbage grinder exists in the structure, it is to be removed if the septic system is not � -� 1 1"1 , ; designed to accommodate a garbage grinder. 11} The installer is responsible for care of excavation around all utilities on the property and SEPT I C SYSTEM D E S l G N protecting the structural integrity of all structures during the installation process of the septic ��✓'�- _ �'`� system. 9 _ FLOW ESTIMATE 12)This plan only represents that a septic system can be installed on the property meeting Title V `r eaRovMs AT 1 GAL/DAY/BEDROOM GL�DAY requirements. ..,.� 13} The property owner shah review design criteria to approve the total number of bedrooms and design flow.installation of the septic system as proposed and receipt of payment for the design SEPt I C TANK shall be deemedapproval of the design'criteria by the property owner or agent of. EYA '�,� CALf DAY x 2 DAYS w AL 14) The validity of this plan shall expire with the expiration of the town installation permit issued for 5Mthis plan or the validity of this plan shall expire on the expiration of the Certificate of Compliance USr. IDS GALLON SEPTIC TANK CFYAP- IWLT•. ---- issued for the instaNatior of the proposed system on this plan. ..- i,, 01 L• ASSORP� 10 SYSTEM -, tl fSRE . v f .- BOTTOis AREA: 1Z -7 Z �7, ' l� = G CGL !i r '►" A�q , f UJ SEPTIC SYSTEM SECTION .:;2,_ , Joa e. -7'V�k, _ �. _A_ Wy s �Oct , t: _�- --•-_._ J � � � f r i T" F � � � i � (Du 7'�.~} fAz � 2•'U-i' �.. z,. `��'D.)� £�_—�1 i�+ �r�-�{.., , SEPTIC TANG= i / .. -4 �C12- DAVID I i Q.O �r X n 1,� L - ►� sore , � SITE AND SEWAGE PLAN c'�..� t..d �.r► s ''/ %t v q nd� 10�8 LOCAT ION : ��� �7 -� :; � .r' PREPARED FOR : _ 9 -- 1 SCALE i ,r DATE: t� I 0 Zo��� -- 9� ~� . DAV D MASON 4. D B C ENVIRONMENTAL DESIGNS DATE HEALTH AGENT 7