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0195 MAPLE STREET - Health
1` ale Street West]Barnstable A— 132 - 006 a - v CERTIFICATE OF ANALYSIS Page: 1 Barnstable County Health Laboratory ysscHLs�Sf Report Prepared For: Report Dated: 1/14/2009 Carafoli/Murelle Order No.: �G0950469 Box 273 W. Barnstable, MA 02668 Laboratory ID#: 0950469-01 Description: Water-Drinking Water Sample#: Sampling Location 195 Maple St.W.Barnstable MA Collected: 1/12/2009 Collected by: J.Carafoli Received: 1/12/2009 Routine ITEM RESULT UNITS RL MCL Method# Tested i Nitrate as Nitrogen ND mg/L 0.10 10 EPA 300.0 1/12/2009 Copper 0.13 mg/L 0.10 1.3 SM 31 I1B 1/13/2009 ND mg/L 0.10 0.3 SM3111B 1/13/2009 Sodium 11 mg/L 1.0 20 SM 3111B 1/13/2009 Total Coliform Absent P/A 0 0 SM9223 1/12/2009 Conductance 120 umohs/cm 2.0 EPA 120.1 1/12/2009 pH 6.4 pH-units 0 SM 4500 H-B 1/12/2009 Water sample meets the recommended limits for drinking water of all the above tested parameters. Approved B —_�'�'�u�_'` (Lab ector) /) < ND=None Detected RL = Reporting Limit MCL=Maximum Contaminant Level Superior Court House, PO. Box 427, Barnstable, MA 02630 Ph: 508-375-6605 TOWN OF BARNSTABLE O�► LOCATION SEWAGE # OD� V LLAGE (h295 Vwv L6 L�_ S ESSOR'S MAP & LOT Z`3� 6 elt INSTALLER'S NAME&PHONE NO. t M—Z0I0 SEPTIC TANK CAPACITY LEACHING FACILITY: (type) �� C (size) NO.OF BEDROOMS ' BUILDER OR OWNER PERMTTDATE: COMPLIANCE DATE: " Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist 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 Z3 A � Ilk No. ap O _ O Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer. Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS application for 30i5po.5al bpeum Construction i3ermit Application for a Permit to Construct( )Repair(X)Upgrade( )Abandon( ) El Complete System Rf Individual Components Location Address or Lot No. 1�� ��P(�f? Owner's Name,Address and Tel.No. a3�. S9 — 7� /3 61rvw S k4-to LA.— Donna M Assessor's Map/Parcel t k t'3 D o"'T Co.,vT Oe�3.x 0®6 " /113 t— 3yia 9 Installer's Name,Address,and Tel No. Designer's Name,Address and Tel.No.. Type of Building: Dwelling No.of Bedrooms_ Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) ",e /,,-g_g, lel: Ao J'-e�0�7 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 Certifi- cate of Compliance has been issued by thisJ3D d of Health. Signed Date Application Approved by Date Application Disapproved for the following reasons Permit No. a0 0 7 — 2-3 26 Date Issued 6` `0 7 vo No. a d o 7'- a` O W Fee THE COMMONWEALTH OF MASSACHUSETTS , Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS !. Zipplication for �Nopogal b gtem Congtruction Permit Application for a Permit to Construct( . )Repair y( )Upgrade( )Abandon( ) ❑Complete System Q Individual Components Location Address or Lot No. 015 l e S r Owner's Name,Address and Tel.No. .,,,, . 6AivV s Vah(A— Dann, M-r j4H H 239- a Assessor's Map/Parcel r G to 3 O u.--t C 0,.-T st- l.c c 31124 21 Installer's Name,Address,and Tel.No. ' ,Designer's Name,Address and Tel.No. ou$�re1� �An�4�a y f g o x too; ('ano—ic.. Oz563 20 IVON@ Type of Building: t Dwelling No.of Bedrooms .. Lot Size sq.ft. Garbage Grinder c ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) _ .- Other Fixtures 7 Design Flow '�: `gallons per•day...Calculate)d°daily flow gallons. Plan..Date Number of sheets Revision Date 5 Title ..4 sY Size of Septic Tank Type of S.A.S. t Description of Soil x Nature of Repairs or Alterations(Answer when applicable) ,QA,O///-" Date last inspected: r Agreement: i�J 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 Certifi- cate-of Compliance has been issued by this Board of Health. Signed Date S-/2 Application Approved by Date J . Application Disapproved for the following reasons `% t Permit No. 0 0 7 ' 3 Date Issued h' �1-0 7 N,- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired (,ice )Upgraded( ) Abandoned( )by ;;n if,© /a( LA.' at /! /YI .,1-e r i j.✓ 1,444- has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No.�2 007- 2 3K dated h- c 1-O 7 Installer d6 d".s xG e/V JAI i2a97i1- C Designer --� The issuance of this permit shall not be construed as a guarantee that the system will fu�nctfon as/des'gned. Date / // Inspector . . Clf} --- ---� Fee r THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS migpogat *pgtem Congtruction permit Permission is hereby granted to Construct( )Repair V )Upgrade( )Abandon( ) System located at /9'f /'NA-va/o and as described in the above Application for Disposal System Construction Permit. The applicant recognizes hisger 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 _ l � Date:__ — Approved by C rv114pl J{v ter a a _ �r i ® Complete items 1,2,and 3.Also complete A Signature item 4 if Restricted Delivery Is desired. X ❑Agent ® Print your name and address on the reverse ❑Addressee so that we can return the card to you. B. Received by(Panted Name) C. Date of Delivery ® Attach this card to the back of the mailpiece, or on the front if space permits. 1. Article Addressed to: D. Is delivery address different from Item 1? ❑Yes If YES,enter delivery address below: ❑ No Ms. Donna Murphy 195 Maple Street West Barnstable, MA 02668 3. Service Type ❑Certified Mail ❑Express Mail ❑Registered ❑Return Receipt for Merchandise ❑Insured Mail ❑C.O.D. 4. Restricted Delivery?(Extra Fee) 0 Yes 2. Article Number (Riansfer from service label) �_ 7005 1160 0 o o 0 0191 3233 i IS PS Fom,3811,February 2004t Domestic Return Receipt 102595 o2-M-15ap ' ff. I m D m 1 ` ' nj II gum r f ... �.. O Postage $ •A. ` C3 C3 certified Fee � JJJ i O Return Receipt Fee ! { U�l4stinerk I. (Endorsement Required) S �� Here A Re 'ad Delivery Fee (Endorsement Required) Lr7 Total Postage&Fees $ O Sent o S Street Apt--- or PO Box No. --------------�g`5"---- � ".......................... Ci tate,ZI Q 4 rnstCL Ab X �4 0 :11 11 Town of Barnstable ��OFtHE Tp��o Regulatory Services s�nB .* Thomas F. Geiler, Director MASS.BARN9�A : •0�A Public Health Division rED MA'S Thomas McKean,Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 May 28, 2007 Ms Donna Murphy 195 Maple Street West Barnstable, MA 02668 The septic system located at 195 Maple Street,West Barnstable, MA was last inspected on April 6th, 2007,by Patrick M. O'Connell, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system"Conditionally Fails"under the guidelines of 1995 TITLE 5 ( 310 CMR 15.00) due to.the following: Septic tank is leaking and needs to be replaced. Distribution box is decayed and leaking. You have 60 days from the date of the system failure to bring the system into compliance. If there are any questions about this reminder,please feel free to contact the Barnstable Health Department. BARNSTABLE HEALTH DEP TMENT Thomas A. McKean, R.S., C.H.O. Agent of the Board of Health \ Town of Barnstable CF tHE 1p� yP� ti� Regulatory Services ;QB, ,SrAB p; Thomas F. Geiler, Director pvp 039. 0 Public Health Division Thomas McKean, Director 200 Main Street,Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 May 28, 2007 Ms Donna Murphy 195 Maple Street West Barnstable, MA 02668 The septic system located at 195 Maple Street,West Barnstable, MA was last inspected on -- April-e,-2OO-T,-by-P-atriGk-M:O'Connell-a-certifed-soptiG-irrspecto-r-€o-r-the-St-ate-o--f- - Massachusetts. The inspection of the septic system showed that the system "Conditionally Fails"under the guidelines of 1995.TITLE 5 ( 310 CMR 15.00)due to the following: Septic tank is leaking and needs to be replaced. Distribution box is decayed and leaking. You have 60 days from the date of the system failure to bring the system into compliance. If there are any questions about this reminder, please feel free to contact the Barnstable Health Department. BARNSTABLE HEALTH DEP TMENT Thomas.A. McKean,R.S., C.H.O. Agent of the Board of Health COMMONWEALTH OF MASSACHUSETTS W EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS d DEPARTMENT OF ENVIRONMENTAL PROTECTION t VW In SVey i2C9 ooL TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 195 Maple Street West Barnstable MA 02668 Owner's Name: Donna Murphy Owner's Address: 1963 Dory Ct. Naples FL.34109 _,-' Date of Inspection: April 6,2007 Job#07-60 'PP C, Name of Inspector: PATRICK M.O'CONNELL Company Name: SEPTIC INSPECTION SERVICES CO. Mailing Address: 189 CAMMETT ROAD MARSTONS MILLS MA 02648 Telephone Number: 508-428-1779 ` ? CERTIFICATION STATEMENT cn I certify that I have personally inspected the sewage disposal system at this address and that the informati' n reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: _ Passes _X_ Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: 4/6/07 The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments: Leaching pit has never been more than half full,septic tank is leaking and needs to be replaced.Distribution box is decayed and leaking. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Page 2 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 195 Maple Street,West Barnstable Owner: Donna Murphy Date of Inspection: April 6,2007 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: XX _XX_ 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. Tank and d-box need to be replaced Answer yes,no or not determined(Y,N,ND) in the for the following statements. If"not determined"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: f Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 195 Maple Street,West Barnstable Owner: Donna Murphy Date of Inspection: April 6,2007 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. I. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(I)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. — The system has a septic tank and SAS and the SAS is within a Zone I of a public water supply. — The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance **This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: r Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 195 Maple Street,West Barnstable Owner: Donna Murphy Date of Inspection: April 6,2007 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No _X_ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool — _X_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool _X_ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool — —X— Liquid depth in cesspool is less than 6"below invert or available volume is less than_day flow _X_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped —X— Any portion of the SAS,cesspool or privy is below high ground water elevation. _X— Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _X_ Any portion of a cesspool or privy is within a Zone 1 of a public well. —X— Any portion of a cesspool or privy is within 50 feet of a private water supply well. —X— Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.) _No_(Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no the system is within 400 feet of a surface drinking water supply — _ the system is within 200 feet of a tributary to a surface drinking water supply _ — the system is located in a nitrogen sensitive area(interim Wellhead Protection.Area—IWPA)or a mapped Zone 11 of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. i Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 195 Maple Street,West Barnstable Owner: Donna Murphy Date of Inspection: April 6,2007 Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No — _X_ Pumping information was provided by the owner,occupant,or Board of Health _X_ Were any of the system components pumped out in the previous two weeks? _X_ Has the system received normal flows in the previous two week period ? _X_ Have large volumes of water been introduced to the system recently or as part of this inspection? _X_ _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) _X_ — Was the facility or dwelling inspected for signs of sewage back up'? _X_ — Was the site inspected for signs of break out? _X_ _ Were all system components,excluding the SAS, located on site'? _X_ — Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum ? X_ — Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems'? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: Yes no _X_ — Existing information. For example,a plan at the Board of Health. X_ — Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)(310 CMR 15.302(3)(b)) Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 195 Maple Street,West Barnstable Owner: Donna Murphy Date of Inspection: April 6,2007 RESIDENTIAL FLOW CONDITIONS Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):330 Number of current residents: 0 Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required] Laundry system inspected(yes or no): Seasonal use: (yes or no): Yes Water meter readings, if available(last 2 years usage(gpd)): N/A Well Water Sump pump(yes or no): No Last date of occupancy: Unknown COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system (yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records: None Source of information: Was system pumped as part of the inspection(yes or no): No If yes,volume pumped: gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM _X_Septic tank,distribution box,soil absorption system —Single cesspool _Overflow cesspool _Privy _Shared system(yes or no)(if yes, attach previous inspection records, if any) _Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) —Tight tank _Attach a copy of the DEP approval _Other(describe): Approximate age of all components,date installed(if known)and source of information: Compliance date: 8/18/88 Were sewage odors detected when arriving at the site(yes or no): No f Page 7 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 195 Maple Street,West Barnstable Owner: Donna Murphy Date of Inspection: April 6,2007 BUILDING SEWER: XX (locate on site plan) Depth below grade: 1' Materials of construction:—X—cast iron _40 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage, etc.): SEPTIC TANK: XX (locate on site plan) Depth below grade: 3" Material of construction:_X_concrete—metal fiberglass—polyethylene —other(explain) If tank is metal list age:— Is age confirmed b certificate) y a Certificate of Compliance(yes or no):—(attach a copy of Dimensions:8.5'long x 5.2'wide—1000 gal. Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: How were dimensions determined: STICK WITH HINGE FLAP. Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Tank is half full all solids.Tank is leakin and must be replaced. GREASE TRAP: No (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(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): i Page 8 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 195 Maple Street,West Barnstable Owner: Donna Murphy Date of Inspection: April 6,2007 TIGHT or HOLDING TANK: No (tank must be pumped at time of inspection) (locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass polyethylene other(explain): Dimensions: Capacity: -gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm it working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: XX (if present must be opened) (locate on site plan) Depth of liquid level above outlet invert: 0" Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): Box is decaved and lea Ane Must be replaced PUMP CHAMBER: No (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.): f Page 9 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 195 Maple Street,West Barnstable Owner: Donna Murphy Date of Inspection: April 6,2007 SOIL ABSORPTION SYSTEM(SAS): XX (locate on site plan,excavation not required) If SAS not located explain why: Type _X_leaching pits,number: One 6x6 pit. _leaching chambers,number: _leaching galleries,number: _leaching trenches,number, length: leaching fields,number,dimensions: _overflow cesspool,number: _innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation, etc.): Pit was empty at time of inspection high stain lines indicate pit has never been more than half full CESSPOOLS: No (cesspool must be pumped as part of inspection) (locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): PRIVY: No (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.): Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 195 Maple Street,West Barnstable Owner: Donna Murphy Date of Inspection: April 6,2007 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet. Locate where public water supply enters the building. Maple Street Well more than 100' ..................... from SAS Driveway . II ................ ............... 60 64 r Page 11 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 195 Maple Street,West Barnstable Owner: Donna Murphy Date of Inspection: April 6,2007 SITE EXAM Slope None Surface water None Check cellar Dry Shallow wells None Estimated depth to ground water: More than 30 feet Please indicate(check)all methods used to determine the high ground water elevation: _Obtained from system design plans on record- If checked,date of design plan reviewed: _X_Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: House and septic system is located 25-30' higher than wetland at rear of property. s f v COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS �) DEPARTMENT OF ENVIRONMENTAL PROTECTION MOM ONE WINTER STREET. BOSTON. NIA 02108 61;-2 _ RECEIVED WILLIAM F.WELD AUG 15 1997 TRUDYCOXE Governo: Secretan HEALTH DEPT. AVID B.STRUHS ARGEO PAUL CELLUCCI TO III OF BAMSTABLE Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTI O Commissioner PART A CERTIFICATION f Property Address:/yS �� S�' i w.AhRo Address of Owner: Date of Inspection: 23'"//-y 7 Of different) Name of Inspector: I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000) Company Name: r-_QW,4 20 C Mailing Address: 65.l WJQQ /PVC 541110w/0H Inl = I S6 3 Telephone Number: �U$- g;3y 6 3 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 Fails Inspector's Signature:��/��/ Date: 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 B, C, or. D: A] SYSTEM PASSES: I 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: SEPTIC SVSTEfyI /.S /A/ VEIE�V C � i,:(J02Klnd� t�OiUi�17"lOry l,IE2Y LITX6 SOLIOS Alin LEfJ04 PIr IS y;vtV 0/vF 7'A/194 FOU , B] SYSTEM CONDITIONALLY PASSES: One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. 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 l of 10 DEP on the World Wide Web: http:/twww.magnet.state.ma.us/dep 0 Printed on Recyded Paper v SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: /77/9f lc sr Owner: #J(IRP-ty 1� . _- • _ Date of Inspection: r" B] SYSTEMJCONDITIONALLY PASSES (continued) Sewage backup,or breakout or high static water level observed in the distribution box is due to broken or obstructed r pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the # iE oa'r'd'of Healtt)r•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 1 r r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: (qS f'nfipLF S?, Owner: rn t/R,4,,-/✓ Date of Inspection: g-DPP 7 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. X _ The site was inspected for signs of breakout. 1 I1 LlV01fV& All system components, 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 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:145^9PIC $i, Owner: MV OHY Date of Inspection: DJ SYSTEM FAILS: / You must indicate either "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 CM R 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: 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 11 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) Peg* 3 of 10 :1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address:I9S MAPLE SIT Owner: m(jap/v Date of Inspection: 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 grade: 'LlAtf-/S Material of construction: _&concrete _metal Fiberglass _Polyethylene _other(explain) i 0 G 14LGo/t✓ zgluIC If tank is metal, lis t age _ Is age confirmed by Certificate of Compliance e(Yes/No) Dimensions: YSludge depth: Distance from top of sludge to bottom of outlet tee or baffle: 30/4CNS Scum thickness: ltvc Distance from top of scum to top of outlet tee or baffle: 7/'VC/W Distance from bottom of scum to bottom of outlet tee or baffle: -�2'M043 How dimensions were determined: 71V d1'I E SUi2� 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.) TANK IS f/V y�572Y CSC$ CoA;DIV00 VERY LI TU, SOWS� CcrQUFT'C &FELES GREASE TRAP: (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 t SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: I CS ^4 PLC Sj Owner: M(JIQP0 Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow: -5,30 g.p.d./bedroom for S.A.S. Number of bedrooms: Number,of current residents: Garbage grinder (yes or(to /t/O Laundry connected to system&or no):As Seasonal use (yes or(MM:NO Water meter readings, if available (last two (2) year usage (gpd): P r ILrAT W L LL Sump Pump (yes otcr!9-16/10 Last date of occupancy: STILL QGC vp C-0 COMMERCI.AUINDUSTRIAL: 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 PUMPING RECORDS and source of information: System pumped as part of inspection: (yes or(!D�UO If yes, volume pumped: gallons Reason for pumping: TYPE OF SYSTEM Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) I/A Technology etc. Copy of up to date contract? Other APPROXIMATE AGE of all components, date installed (if known) and source of information: Sewage odors detected when arriving at the site: (yes orefV0 (revised 04/25/97) Pago 5 of 10 i r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: f K/11016 ST. Owner: in V RPN� Date of Inspection: SOIL ABSORPTION SYSTEM (SAS):I� (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.-PUS' S 1X;Fops /000 G%LLou &64(-1/ PIT leaching chambers, number:__ leaching galleries, number: leaching trenches, number,lenglh: leaching fields, number, dimensions: overflow cesspool, number: Alternative system: Name of Technology: Comments: (note condition of soil, Signs Qf hydraulic failure, level of ponding, condition of yegetation, etc.) RisC LE&H PIT- IS CiULV OtitE �//12D PUt-L ; Pf1' 94S /9 Fool' � � trULFT- /N RfSEk CESSPOOLS: _ (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 SYSTEM INFORMATION (continued) Property Address: CIS `yj4pts sT Owner: fil URP�/, � Date of Inspection: 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: _eoncrete _metal _Fiberglass _Polyethylene _other(explain) Dimensions: Capacity: gallons Design flow: gallons/da� 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: 'T 6 i" OF PO Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) 01V lwcer, oiu6 o urC cr 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 04/25/97) Page 7 of 10 I N + SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: MUIPPH Date of Inspection: 8-l�q7 Depth to Groundwater Z 3 Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on re--ord Observation of Site (Abutting proparty, 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) �/4?� GRD0&,g iN1t'rCR .,w,4P f Tal00 rn AP (revived 09/25/97) Page 10 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: /C]S 1,16PL65T-, Owner: MuRPFIy 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) Le- (revised 04/25/97) Page 9 of 10 TOWN OF BARNSTABLE LOCATION///��l �m SEWAGE # I'ryLAGE (�J ASSESSOR'S MAP & LOT NAME&PHONE N0. ��!h• O SEPTIC TANK CAPACITY f LEACHING FACILITY: (type) size) NO.OF BEDROOMS �� O BUILDER OR OWNER PERMITDATE: C Y" IANCE DATE: Separation Distance Between the: ®` Maximum Adjusted Groundwater Tab I? Bottom of Leaching Facility Feet Private Water Supply Well and Leh ng 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 TOWN OF BARNSTABLE �r SEWAGE VILLAGI; s �ASSLSSOI?'S MAP S- LOT ��� D AINSTALLER'S NAME & PHONE NO. 6 SEPTIC TANK CAPACITY ���� _ LEACHING FAC.ILITY:(type)� .!4 ' 7 NO. OF BEDROOMS-3—_PRIVATE WELL OR .PUBLIC WATER' BUILDER OR OWNER DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED!___ VARIANCE GRANTED: Yes PIo c v ®� ` h b® r T® we,ii No..D 7 Fps..... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH '-� � /��� ...........................................OF....................................... Appliration for Disposal Works Tonstrurtion 1hrutit Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal System at .......................................................... Loc-lion _k�------- ..........I--------- or Lot No. -I....................... . ...... ............... .. ..... .................................................................................................. Owner Address ................... , .......... ..........r-,....... .................................................................................................. Installer Address Type Iding Size Lot............................Sq. feet U Dwelling—No. of Bedrooms........ ................................Expansion Attic Garbage Grinder PL4 Other—Type of Building ........................... No. of persons............................ Showers Cafeteria A4Other fixtures ...................................................................................................................................................... Design Flow................J. ....$��7_gallons per person per day. Total daily flow...........//A......................gallons. 1:4 Septic Tank—Liquid capacity/#&4(4_....gallons Length................ Width._............__ Diameter__._......___._. Depth_......._...._.. Disposal Trench—No Width..............._.... Total Length.................__. Total leaching area....................sq. ft. Seepage Pit No.-Z Diameter.................... Depth below inlet.................... Total leaching area..................sq. f t. 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----__---___-_--_----. rX, Test Pit No. 2................minutes per inch Depth of Test Pit...__.___..._....... Depth to ground water..._._...__._.__....__.. P4 ....................................................................----------------------"------------------*-------------- 0 Description of Soil....................................................................................................................................................................... x U ......................................................................................................................................................................................................... .......................................................................................................................1-1..................... ------- -- ---- U Nature of Repairs or Alterations—Answer when applicable-------_ ................................................................................................................... ..................... ................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of'TTIE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in J.-� operation until a Certificate of Compliance has been ' ued by t e boar A o4 hialth. Signed---- ..... ... .. ......0. ...... .... .................... ..... -Date Application Approved By....... ... ............................ ............. Date Application Disapproved for the following reasons:................................................................................................................ ......................................................................................................................................................................................................... Dat ace- PermitNo.....U..Q........ .............................. Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ....... .. ............................OF.........I.....---..................... ApplirFatinn for Di ipaa a1 Hl.nrki Tonitrnr#ion rrnti# Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System 0-at: Z. .. Location-Add ess or Lot No. _1 Owner Address �. v ' � Installer •- 4k Address UType of ding Size Lot-----.•-•-------------------Sq. feet �-, Dwelling—No. of Bedrooms........ .....................:..........Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building .............. No. of persons............................ Showers a g -------------- ----------••P•-�- ( ) — Cafeteria ( ) Other fixtures -----------------------------------• W Design Flow............... ......gallons per person per day. Total daily flow........... /.,7.......................gallons. WSeptic Tank—Liquid capacity/4,,Je....gallons Length................ Width................ Diameter---------------- Depth................ x Disposal Trench—No. .. ................ Width.................... Total Length...... Total leaching area---------.••_-------sq. ft. Seepage Pit No.../._ g1..��} 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................minutes per inch Depth of Test Pit.................... Depth to ground water........................ fs, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a ......................................................-...........................-----------------------•-•------•-------••--------------•---------•-------- x Description of Soil--------•........................•----------._........._---•---•-.... --•-----------••-•••---------•--•---------•-••-•---•------•--•---........................ . I' U ....----•-•--...-----•--- --------------------------------•--•-•--------•---••----••--------••--••------•--------•-------•••---...------• ... U Nature of Repairs or Alterations—Answer when applicable._--__-.- .' _ "*-_-_.--y .� j �-•.� ----------- -•------------•----•----•---•-------•------------------------------------------------•--•--------•---••-••----- f -------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITIE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been i ed by the board of hh' lth. Signed. -----------•-- -- - :..- ..... -- ..... r Application Approved By............... .,r -rti�...... Date Date Application Disapproved for the following reasons:-------•-------•-•------------------•-••----•---------------------------------•----------...._......••-•--•••-- ............ •------------ •-----•-------------------------- ---•----------...•--•------.-----------.-•-- Date Permit No...... �- Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ................ �� �,�.;.......OF...........(�.�.,.:. � w��Iy��............................. �rrtifirFatje n'(�rrnt�r�i�anr�e THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (� by t • -- ... `> ,a:�> _ ...._.i_....v4e ••---------------------- --------------- .....--------------------•-------•---------- Installer r -------------------------------------------------------------------- has been installed in r1cordance with the provisions of TITIE 5 of The State Sanitary Code as described in the j application for Disposal Works Construction Permit No.._.. --�t---:..... .: ._ ....... dated............... ............................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE = 4... _.. -------------•---•---•--_. Inspector.................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 1 No.....4.&.:-.:-.2, I'EE... i �i��rrn�t� nrkn �nnn�rauan1 .ernti# Permission is hereby granted.............. �r��,_...v�:-._ --------- ------------------------------ -•-----....................... to Construct ( ) or Repair ( an In al Sew ge Disposal Sy tem atNo. 1 �-•--Y........................ y zz: 144 1!���`x • '� r_C� ........................................... Stzeet �- as shown on the application for Disposal Works Construction Permit No... Dated.......................................... r oard of Health DATE. ................................. FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS y TOWN OF BARNSTABLE LOCATION / ; SEWAGE # r O VILLAG ,FASSESSOR'S MAP & LOT INSTALLER'S NAME lti PHONE NO. , SEPTIC TANK CAPACITX LEACHING FACILITY:(type),= � t NO. OF BEDROOMS_3_� PRIVATE WELL OR PUBLIC -WAT'E � BUILDER OR OWNER .DATE PERMIT ISSURD:� DATE COMPLIANCE ISSUED: IP, VARIANCE GRANTED: Yes No J � I i 60 _ � f V yll No.------- ------ :. Fee--------- - ` -- ----�-------.-_ BOARD OF HEALTH TOWN' OF BARNSTABLE Application-for Well Con5tructionpermit Application is hereby made for a permit to Construct (w<Alter ( ), or Repair ( )an individual Well at: ' Location— Address Assessors Map and Parcel - - - -- - -------------------- - — - - - - - ---- - - - -- Owfier Address .srr�or�, Lli'�ZG �ctr n �d a ;7r3 O,�Gc-DNS /yr� r Installer Driller Address Type of Building Dwelling------—-------------------------------------------------------- ' 9 Other - Type of Building ----- No. of Persons----------------------------------------------- _m. "�60 ' .�cN 90U� Ca /D-ia - - - - ------ I Type of Well-- -- -- -- - -- Capacity------- - Purpose of Well----l�/Ji >r e--------------------------------------- I -� Agreement: Tt a undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation - The undersigned further agrees not to place the well in operation until a Certifica a .of Compliance has been issued by the Board of Health.`` Signed - - s---- --` -- - �� -- -- I �--- n date Ap lication Approved By f ------- ---- - I -- ----- ate--------------- Application Disapproved--jor the following reasons:------------------------------------------------------------------------=----=--------- 1 ate �yLL7 9 -- - -------- -------------; a. Issued-----� --- :-----{--- -- -----=----------------�w--------Permit No. ----- --- ------ -- d to �3'!'�''�"5�-�'�'Yiz�'i'C4F2���"#'rifi7:tl��-a�tRY•7�tG�IDit, TdiE��:" - _ BOARD OF HEALTH TOWN OF BARNSTA"BLE 4 Certificate Of Compliance THIS IS TO-CERTIFY, That the Individual Well Constructed.( ), Altered ( ), or Repaired ( ) bY------------=- ---- -- - - - - ---------=----------------------------------------------------- - --- -- Installer at- - - --- --- ------ - -- ------------------------------------------------------—--------------------------------- _has been installed in accordance with the provisions of the Town of.Barnstable Boar of al rivate Well Protection Regulation as described in.the application for Well Construction Permit No. `- %Dated - - t a • ' THE.ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL• FUNCTION SATISFACTORY. DATE ------ -=---- Inspector------------ �=----------------"------ ------------------------ ---------------------------------- BOARD OF -HEALTH TOWN OF BARN STAB LE .sett Con6tructionA3ermit No. - - -- -- ! r{. Fee--- - ----------- Permission t h r by ranted - --- to Constr act lter or ep 'r ) an I divi ual at: Street as shown a plicati o a Well Construction Permit No.- -� - - - - ----------------------- Date - ------- -------------------- -- a( e ------------- - -- -- ---------- ------ -- --- ------ - i Board of Healt DATE--— -- -- -----— 4 s 1p ))) No.---- - T ----- Fee-- -- ---------- BOARD OF HEALTH TOWN OF BARNSTABLE Application,for Vell Congtruct ion Permit Application is hereby made for a permit to Construct (yo<Alter ( ), or Repair ( )an individual Well at: e 7-1EtZ---7- - - --- -- - - - -- -- ---------------------------------------------- Location — Address Assessors Map and Parcel C 10W,0G� .57. !/• /�ST1��L� - - - --- ----- - - - - -- - ------------- , O er Address SrrlUri� �/a ,d elcceAe )0o . a 7d'3 _ - - --- -------------------- -------------------- ------------------------ - Installer Driller Address Type of Building Dwelling--------------------------------------------------------------- Other - Type of Building----------------------------------- No. of Persons---------------------------------------------- �{ BOO ` JC.f/ -9a Q!/C. /O-/ac -°'j] - - - -—- Type of Well- -- -- ------- -- ------ Capacity------- -------ram- - - - - Purpose of Well---- 3/y/EStr<------------------------ - Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation - The undersigned further agrees not to place the well in operation until a Certifica a .of Compliance has been issued by the Board of Health. Signed ----- --- - - ^ - ---------- -�(-" dac---- --t e Application Approved By ------- --- -- - --------------------- date Application Disapproved for the following reasons: —----------------------------------------------------------------------------------------------- -----------------------------------------�---�_-j---------------------------------------------- date Permit No.-- — -- - Issued --- - ------ te---------------- -- - -- < w BOARD OF HEALTH TOWN OF BARNSTABLE Certificate ®f Compliance THIS IS TO CERTIFY, That the Individual Well Constructed ( ), Altered ( ), or Repaired ( ) by------------- ---------------------------------- ------------------------------------- --------------------------------------------------------- ---------------------- Installer at- -— -- ----- ---_-_---------------------------------------------------- has been installed in accordance with the provisions of the Town of Barnstable Boar of all rivate Well Protection Regulation as described in the application for Well Construction Permit No.0----- -- ated------------------------ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE-------------- — -- — - -- ---—- Inspector-------------------------------------------------------------------------- F ' TOWN OF BARNSTABLE �TD LOCATION ' 000, # � c� = VILLAGE ASSESSOR'S MAP & LOT INSTALLERS NAME & PHONENO. SEPTIC;TANK CAPACITY LEACHING FACILITY:(type) (size) /00 NO. OF BEDROOMS PRIVATE W . OR PUBLIC WATER&U ti BUILDER OR OW E -- - /' DATE PERMIT 1 SU;EIS: - ' 4• DATE 'COUPL /4c ISS;U:ED VARIANCE GRt Y� � I • ( : ICI it ii TOWN OF BARNSTABLE �] qj LOCATIC v�0$ 4f�c $f SEWAGE , VILLAGE ASSESSOR'S MAP & LOT INSTALLER'S NAME PHONE NO. A & B CM-0775-626 SEPTIC TANK CAPACITY AP LEACHING BACILITY:(type) ���' (aim) /,AAgo d:�,, L NO. OF BEDROOMS_ _PRIVATE WELL OR PUBLIC WATER��� BUILDER`OR OWNER 191 DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED; Vq I VARIANCE GRANTED: Yes _ No �4 0 TOWN OF BARNSTABL E LOCATION ► SEWAGE #_ YILLAG ,ASSESSOR'S MAP & LOTOc _ OW4i `'►6?-boos INSTALLER'S NAME 14 PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY-(type) _ (size) /6�0 F NO...OF BEDROOMS PRIVATE WELL OR PUBLIC WATER 1. BUILDER OR OWNER _ DATE PERMIT ISSUE r DATE COMPLIANCE ISSUED_ �' /Ff, til — VARIANCE GRANTED: Yes No_�� _ 1 �ALA 1' �p �V Mr` b \� c t b0 � -To wei� —_ 1 • � P I� t► / EM✓IROTECH LABORATORIES, INC. --- MA Cert.-No.: M-MA-063 1 - _ 449 Rte.130 Sandwich, MA 02563 (508) 888-6460 1800-339-6460 FAX (508) 888-6446 CLIENT: Donna Murphy LOCATION: 195 Maple St. ADDRESS: 195 Maple St. W. Barnstable, MA 02668 W. Barnstable, MA 02668 COLLECTED BY: Desmond Wells SAMPLE DATE: 9-12-97 SAMPLE TIME: 12:OOPM WATER SAMPLE TYPE: New Well DATE RECEIVED: 9-12-97 LAB I.D.#: 979302 WELL SPECS.: 47 637 35' RESULTS OF ANALYSIS: Parameters Units Recommended Results Method Limits Coliform bacteria /100ml 0 0 9222 B pH pH units 6.5-8.5 6.00 4500 H+ Conductance umhos/cm 500 153 120.1 Sodium mg/L 28.0 - 10.8 200.7 Nitrate-N/Nitrite-N mg/L 10.0 0.24 4500-NO3 E Iron mg/L 0.3 0.06 200.7 Manganese mg/L 0.05 0.003 200.7 Volatile Organics ug/L See Report EPA 502.2 Chloroform ug/L 100 0.99 COMMENTS: pH is below recommended limit and may have corrosive characteristics. YES WATER IS SUITABLE FOR DRINKING PURPOSES FOR PARAMETERS TESTED. Date4;�/ — fi6'rlala J. Saari Laboratory Dire or <=less than >=greater than TNTC=too numerous to count l Page 2 TOXIKON CORP. REPORT York Order # 97-09-301 Received: 09/17/97 Results by Sample SAMPLE ID 979303 FRACTION 01A TEST CODE 502 2 NAME VOC IN H2O BY PURGE & TRAP Date & Time Collected 09/12/97 12:00:00 Category WATER Dichlorodifluoromethane ND 0.50 1,1,1,2-Tetrachloroethane ND 0.50 Chloromethane ND 0.50 1,1-Dichloropropene ND 0.50 Vinyl Chloride ND 0.50 Bromoform ND 0.50 Bromomethane ND 0.50 1,1,2,2-Tetrachloroethane ND 0.50 Chloroethane ND 0.50 1,2,3-Trichloropropane ND 0.50 Trichlorofluoromethane ND 0.50 Bromobenzene ND 0.50 1,1-Dichloroethene ND 0.50 2-Chlorotoluene ND 0.50 Methyiere Chloride ND 0.50 4-Chlorotoluene ND 0.50 trans-1,2-Dichloroethene ND 0.50 1,3-Dichlorobenzene ND 0.50 1,1-Dichloroethane ND 0.50 1,4-Dichlorobenzene ND 0.50 cis-1,2-Dichloroethene ND 0.50 1,2-Dichlorobenzene ND 0.50 2,2-Dichloropropane ND 0.50 1,2-Dibromo-3-Chloropropane ND 0.50 Chloroform 0.99 0.50 1,2,4-Trichlorobenzene ND 0.50 Bromochloromethane ND 0.50 Hexachlorobutadiene ND 0.50 1,1,1-Trichloroethane ND 0.50 1,2,3-Trichlorobenzene ND 0.50 1,1-Dichloropropene ND 0.50 Benzene ND 0.50 Carbon Tetrachloride ND 0.50 -J oluene ND 0.50 1,2-Dichloroethane ND 0.50 'Ethylbenzene ND 0.50 Trichloroethene ND 0.50 m-Xylene ND 0.50 1,2-Dichloropropane ND 0.50 p-Xylene ND 0.50 Bromodichloromethane ND 0.50 o-Xylene ND 0.50 Dibromomethane,' ND 0.50 Styrene ND 0.50 cis-1,3-Dichloropropene ND 0.50 Isopropylbenzene ND 0.50 trans-1,3-Dichloropropene ND 0.50 n-Propylbenzene ND 0.50 1,1,2-Trichloroethane ND 0.50 1,3,5-Trimethylbenzene ND 0.50 1,3-Dichloropropane ND 0.50 tert-Butylbenzene ND 0.50 Tetrachloroethene ND 0.50 1,2,4-Trimethylbenzene ND 0.50 Dibromochloromethane ND 0.50 sec-Butylbenzene ND 0.50 1,2-Dibromoethane ND 0.50 p-Isopropyltoluene ND 0.50 Chlorobenzene ND 0.50 n-Butylbenzene ND 0.50 Napthalene ND 0.50 Notes and Definitions for this Report: DATE RUN 09/19/97 ANALYST XL INSTRUMENT B UNITS ug/L DILUTION 1 ND = NOT DETECTED AT DETECTION LIMITS Department of Environmental Management/Division of Water Resources WELL COMPLETION REPORT WELL LOCATION GEOGRAPHIC DESCRIPTION Address ��� 11d &� CC/• f7/VS 7�? L feet N S E W of (feet) (circle) City/Town Well owner �DNNA �h�/�r� r/ (road) Address J fy /�jA�CE.S�� / N S E W of W. , q q/14S 7;V6GE 1I4 D0266Se (mi in tenths) (circle) Board of Health permit obtained: yes 101" no ❑ intersect. w/ (road) WELL USE WELL DATA Domestic❑Public❑ Industrial ❑ Total well depth ft. Monitoring❑ Other Depth to bedrock ft. Water-bearing rock/unconsolidated material: Method drilled � 8� Description Date drilled Water-bearing zones: CASING 1) From To Type ^',� �U� 2) From To Length 40 ft. Dia(I.D.)—T in. 3) From To Length into bedrock ft. Gravel pack well: dia. Protective well seal: dia. Screen: Grout ❑ Other ! Slot#�length fromto STATIC WATER.LEVEL(all wells) Static water level below land surface ft. Date r /2 'Z WELL TEST(production wells) Drawdown 6 ft. after pumping _R hr. min. at ap gpm How measured 4 r 2 o ecovery 1,&12r-fV1-after1--R--4r.. min. LOG of FORMATIONS COMMENTS 0 Materials From To 4^/h• a l Driller-7— //0( �• �; 5� r1 /o S/ Firm o1E�/9iDji1� ✓vE�c � iGG�/vg -27.361Y6 Address �i �'�y✓�3E� ��- E-.�r City/Town Superv' ing Driller Reg.# Signature of supervising registered well dri ler Please print firmly BOARD OF HEALTH COPY {