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Home My WebLink About0039 MEADOW LANE - Health 39 Med®w Lane 133-005-003 - -- - West Barnstable A f - -pan cQ to 6 j . f 1 4 R u 4 , �1 •.n, e Q ^ t P�I - s Jop y ;.' { In An oil wAO .ItY Ski '` 'i •n' t �tr.;` .. .. _ 3 y X f � �~ T '��+fit �'��t+y.,M�c ? '�"q L��.•s� 5 - � - - . 3 Y No. ( Fee BOARD OF HEALTH TOWN OF SARNSTABLE 2pplicatiou _for Vern Cougtructiou Vertu Application is hereby made for a permit to Construct ; Alter( ), or Repair( ) an individual well at: } GMec�av IVY- , 1A) r0eM bk-, 3 10blq ��D `.3 f j��Lo,,catiioon�-�Ayddrreess � I� � fAsssesss�orrss Map and Parcel�r 1 Cif I(t'V l / o n / �l 'lam/ ll'.0 6� ; W• l.Jt+U n S.L1qk— Owner Address s— "A Installer-Driller Address Type of Building Dwelling X Other-Type of Building No. of Persons Type of Well LF Q VVL Capacity (O i qtt� Purpose of Well g-&-h c, Agreement: The undersigned agrees to install the afore described 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 Certi Cate of Compliance has been issued by the Board of Health. Signed I..✓ D to Application Approved By ��- Date Application Disapproved for the following reasons: ,q r Date Permit No. [� / r lia Issued Date ---------------------------------------------------------------------------------------------- ----------- BOARD OF HEALTH TOWN OF BARNSTABLE (Certificate of Compliance THIS IS TO CERTIFY,that the individual well Constructed , Altered( ), or Repaired( ) Installer at �39 N AjabLO LAM I W. has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Prote tion Regulation as described in the application for Well Construction Permit No. ' �-O/4 Dated -j 'o� THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORILY. Date Inspector -----------—------------------------- - _ -- No. �,� /--��tv Fee BOARD OF HEALTH i TOWN &F—IBARNSTABLE ' ZIppricaction f or Very Cou5tructiou Permit Application is hereby made for a permit to Construct`W, Alter( ), or Repair( ) an individual well at: Location-Address' Assessors Map and Parcel 1 I I Glnc�a► cup 1 Owner Address rn�n 1&II t)rIIlicy� , (nc . �. 2793 C) r L_0(Iy)c, AA-A c)?- Installer-Driller -, Address Type of Building i Dwelling X Other-Type of Building No. of Persons ..... TYPe of Well Purpose of Well (•�nt`(�2�`t-� Agreement: The undersigned agrees to install the afore described individual well in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation-The undersigned further agrees not to place the well in operation until a Certificate of Compliance has been issued by the Board of Health. 31 K Signed 2U�J Date Application Approved By Date Application Disapproved for the following reasons: i rr Date Permit No. < � (V(D Issued Date + BOARD OF HEALTH TOWN OF BARNSTABLE Certificate of Compliance THIS IS TO CERTIFY,that the individual well Constructed;(, Altered( ), or Repaired( ) by Ul Xc c� E bra ltcro\ .Inc.. Installer 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.l,3-'o- -4& Dated THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORILY. Date Inspector BOARD OF HEALTH TOWN OF BARNSTABLE Ivell Cori.5truction permit No. � _ ��a/ Fee Permission is hereby granted to UPSMOna We�11 1-)Y 1 t on I}1C- Installer to Construct ), Alter( ), or Repair( an individual well at: No. �1 WI LA_ttyk) `a 6mn(�T� W P, Street as shown on the application for a Well Construction Permit No. --.,Dated _�)?/,/Io l Date �./, /� Approved By �j +- Lo -r -r•;d ._.f_. .ti fit- _ c y r 14 1 t t i r rat � � --' �• LP t •*` lop j f THE FOLLOWING IS/ARE THE BEST IMAGES FROM POOR QUALITY ORIGINALS) I M ^C&L DATA T-. c.Ir�N4x�.S few-pj.-dI =-- �fi ?44 y I.OAT+w'W�°�TACEa l gh °} i �•P1pG f1Tu1•I�lot u,aaF os ee x ni�so. w.*ro.si'�o -44 'ram a I.c> - 5.9r�Ja�sT9c P,C-ICE. 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R,'.e•�ti scr�..a s:�c' a.• -'.=• �� •_��-1 1� `' -11yL `" S _`_"� F�.'3`_. � \ �...2�; ✓ \\1 ' �\�." 1� •" 1_ �r �ri�I Ii"rteGs67�R�3E —°h �r 0 C s ��:t•� �z-:a,� r,;�y sue-; j � � - ��,�o-" ��- �,;:�� '�, •�- ;065 (P 5�' n.z ITE ..+��1.16C��uGr.l '®`� '�_ / y`i' scP(°7 r � ncFs.a'°':f''r sa•. •�t_rl- -.r."-a_� CC 2 i� IIA i Y•�- _9 Pa ' � LAND 1+..��IGY�•�J N_�� rY.p ,'J �i�ti�0.{� MA.. j E Le 1aee+ta)Ytt,rleu s p�Gu+ , ' •E. '17AV r f / EMYRO TECH LABORATORIES,INC. Z NO.:A-MA 063 fd 51 8 Jan Sebastian Drive Unit 12 Sandwich,MA 02563 (508)888-6460 1-800--M-6460 j f P-2/t 7 rv"r(308)888-6446 s s� Client Name Coughlan,Gerry Location 39 Meadow Lam PQ 00 Address PO Box 517 W Barnstable,MA a Yarmouth,MA 02675 Sample Date Ot/26/15 Collected By Client Sample Time NA Soark Tppie V&M D re Baited ataws Lab Order Number DW-150172 Well Specs. NA eu � - in�iut�. Tlituel�al[t�dl AOC MR ,�ta�is.Ktyyr�Yt►r10 l7ki� , = m�nti�' ;.�ilodl, tlltrdv � pH pH units 6.5-8.5 6.38 SM4500-H-B 1/26/2015 LL Specific Conductances umhos/cm 500 125 EPA 120.1 1/26/2015 LL Nitrite-N mg/L 1.00 <0-006 EPA 300.0 1/26/2015 LL Nitrate-N mg/L 10.0 1.94 EPA 300.0 1/26/2015 LL Sodium mg/L 20.0 10 3 EPA 200.7 1/30/2015 MC _ _. .. —.... _..__ . .._ -- Totallronn ng/L 0.3 0.26 EPA 200.7 1/30/2015 MC Manganesen mg/L 0.05 0.13 EPA 200.7 1/30/2015 MC Tal Coliform(Presence/Absence) Present/Absent Absent -A SM92236 1/26/2015 MC ot Comments: pH is below recommended limit and may have corrosive characteristics. Manganese is not a health hazard,but may cause staining and/or give water an odor or taste. Water meets EPA standards and is suitable for drinking for parameters tested. Abm*&C--;Jv� Laboratory Diredorl . BRL=Belrnv Reportable Limits 'See Attached Page 1 of 1 ❑Certification is not available.for this analyze,for non;potable water samples.. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments w 39 Meadow Lane IIX) Property Address William Chapman Owner owner's Name =A information is X required for every W.Barnstable MA 02668 1/26/15,. page. City/Town State Zip Code Date of 9ppection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information �/ filling out forms # ,Z Z 3 on the computer, use only the tab 1. Inspector: key to move your cursor-do not Robert Paolini use the return key. Name of Inspector Robert Paolini Septic Service 4 -4 Company Name 17 Playground Lane )� Company Address I Yarmouthport MA 02675 City/Town State Zip Code 508 362-3555 S14454 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: 0 Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 1/26115 Inspector's Sig atu Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 z Jed VS I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Meadow Lane Property Address William Chapman Owner Owner's Name information is required for every W Barnstable MA 02668 1/26/15 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: Z I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The septic system is in proper working order at the present time B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 39 Meadow Lane Property Address William Chapman Owner Owner's Name information is W Barnstable MA 02668 1/26/15 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins-3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Meadow Lane Property Address William Chapman Owner Owner's Name information is required for every W Barnstable MA 02668 1/26/15 page. Cityrrown State Zip Code Date of Inspection B. Certification (cunt.) 2. System will fail unless the Board of Health(and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ 0 Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ 0 Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ 0 Liquid depth in cesspool is less than 6" below invert or available volume is less than day flow t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form A a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Meadow Lane Property Address William Chapman Owner owner's Name information is W Barnstable MA 02668 1/26/15 required for every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ❑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. 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. ❑ 0 Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ 0 Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ M The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ 0 The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 39 Meadow Lane Property Address William Chapman Owner owner's Name information is required for every W Barnstable MA 02668 1/26/15 page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ❑x ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ Z 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? ED ❑ 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? • ❑ 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: ❑x ❑ Existing information. For example, a plan at the Board of Health. ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M °r 39 Meadow Lane Property Address William Chapman Owner Owner's Name information is required for every W Barnstable MA 02668 1/26/15 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: NA Does residence have a garbage grinder? - ❑ Yes No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes Fx1 No information in this report.) Laundry system inspected? 0 Yes ❑ No Seasonal use? ❑ Yes 0 No Water meter readings, if available last 2 ears usage d Well Water 9 ( Y 9 (9p ))� Detail: Sump pump? ❑ Yes No Last date of occupancy: NA Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Meadow Lane Property Address William Chapman Owner Owner's Name information is W gamstable MA 02668 1/26/15 required for every page. CityTrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Yarmouth BOH Was system pumped as part of the inspection? ❑ Yes 0 No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Tank pumped 9/14 for maintenance. 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) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Meadow Lane Property Address William Chapman Owner Owner's Name information is required for every W Barnstable MA 02668 1/26/15 page. CitylTown State Zip Code Date of Inspection D. System Information (cunt.) Approximate age of all components, date installed(if known) and source of information: Were sewage odors detected when arriving at the site? ❑ Yes No Building Sewer(locate on site plan): Depth below grade: 1' feet Material of construction: ❑ cast iron ❑x 40 PVC ❑ other(explain): Distance from private water supply well or suction line: 10+ feet Comments (on condition of joints, venting, evidence of leakage, etc.): Joints appear tight.No evidence of Ieakage.System vented through the building vents. Septic Tank(locate on site plan): Depth below grade: 1.5' feet Material of construction: I5X] concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gl Sludge depth: 3" t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Meadow Lane Property Address William Chapman Owner Owner s Name information is MA 02668 1 1 required for every WBarnstable /26/ 5 page. City/Town State Zip Code Date of Inspection D. System Information (cunt.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 33" Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 12" How were dimensions determined? Measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pump tank every 2 years.Inlet and outlet tees are in place.No evidence of Ieakage.Tank appears structurally sound. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Meadow Lane Property Address William Chapman Owner Owner's Name information is required for every W Barnstable MA 02668 1/26/15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain).- Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order. ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 39 Meadow Lane Property Address William Chapman Owner Owner's Name information is required for every W Barnstable MA 02668 1/26/15 page. City/Town State Zip Code Date of Inspection D. System Information (cunt.) Distribution Box(if present must be opened) (locate on site plan).- Depth of liquid level above outlet invert No 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 level.Box has one outlet laterals.No evidence of solids carryover.No evidence of leakage. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No" Alarms in working order: ❑ Yes ❑ No" Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Meadow Lane Property Address William Chapman Owner Owner's Name information is required for every W Barnstable MA 02668 1/26/15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑x leaching pits number: 1 6'x6' LP ❑ 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.): Sandy soil.No signs of hydraulic failure. 50" below invert at time of inspection. Cesspools(cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments '~ 39 Meadow Lane Property Address William Chapman Owner Owner's Name information is required for every W Barnstable MA 02668 1/26/15 page. Cityrrown State Zip Code Date of Inspection D. System Information (cunt.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Seviage Disposal System•Page 14 of 17 Commonwealth.of(Massachusetts Title, 5 Official Inspection Form Subsurface Sewage,Disposal System:Form-Not.#or Voluntary Assessments: 33 Crowes Purchase: Rd. Property Address. Joan Curran Owner Ownees Name, intormabon is S.Yarmouth MA 02664 requ'aed for every page, City/Town State Zip Code Date of Inspection D. YStem Information (cunt.) Sketch Of Sewage Disposal System:Provide a view of the sewage disposalsystem, including ties to at least two permanent'reference landmarks or benchmarks. Loi ate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below- hand-sketch in the area below O drawing attached separately IZ2 t5kno 4 .} s 3113. Title 5 0fficW :Form:Submdace Sewago Disposal System..:Page 150117 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 39 Meadow Lane Property Address William Chapman Owner owner's Name information is required forevery W Barnstable MA 02668 1/26/15 page. City/Town State Zip Code Date of Inspection D. System Information (cunt.) Site Exam: Check Slope ❑x Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: Bottom of leaching 14' feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: As-Built ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: USED:USGS observation well data.USED:Technical bulletin 92-0001 annual ranges of groundwater elevations. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Meadow Lane Property Address William Chapman Owner owner's Name _ information is required for every W Barnstable MA 02668 1/26/15 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist Inspection Summary: A, B, C, D, or E checked ❑x Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ❑x System Information—Estimated depth to high groundwater Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 AsBuilt Pagel of 1 TOWN OF BARNSTABLE LOCATION SEWAGE # t33 --aa5 ._ 0.03 VILLAGE L4/r,7gZ ! ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITY /d e) 0' LEACHING FACILITY:(type)/0V 4/0 (sue) NO. OF BEDROOMS_ 2 PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER 449-L/ &EejE ' DATE PERMIT ISSUED: -/0 DATE COMPLIANCE ISSUED• /0 VARIANCE GRANTED: Yes No Ta/4 K Do f3oX r L&ACh �dl 13 A/ D J e0 0 65 �- http://issgl2/intranet/propdata/prebuilt.aspx?mappar=133005003&seq=1 2/13/2015 TOWN OF BARNSTABLE f l, 8 `� LOCA'nON 7'� 4L54 0/vl�''' '.SEWAGE # I13 - 605 m Pi03 VILLAGE JAlrS' /V Z ASSESSOR'S MAP 6T LOT 4 dy INSTALLER'S NAME &.PHONE NO. SEPTIC TANK CAPACITY ZL-O 0 LEACHING FACILITY:(type)/6A0 �/� (size) NO. OF BEDROOMS _PRIVATE WELL OR PUBLIC WATER/&dZe BUILDER OR OWNER RA,/Ilj /A/g%/l &Egg ° DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No iN -7� L� 22 L&AG# lair � t'nn►u y No. 9 Fxs......24;..-... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH AssE c�AO w� Appliration for -Bispootti Vorko Tonotrurtion Per Application is hereby made for a Permit to Construct ) or Repair ( ) an Individual Sewage Disposal System - q �� c�J C¢dl/ �t s 8v,,•,�-b ........ .. .....ation:Ad ess...................................................... or..t.N-. ... •- ..-..............-.. .. ...........................`..---• ...r ------. ............._. -___..t: Owner " A ress 94 .............. -. -•••- —• -• ........•.... ........................... .....------------------ ...................... ... a Installer Address Type of Building 5 Size Lot............................Sq. feet aDwelling—No. of Bedrooms............................................Expansion Attic ( ) _-b� Ga?age Grinder ( ) Rar Other—Type of Building ............................ No. of persons............................ Showery ( — Cafeteria ( ) Other tures ...................................... W Design Flow.............. 1_0.......... �' gallons per pin p?r day. Total drily�ow.......................................... }l • WSeptic Tank—Liquid capacityl gallons Length._ ._4_... Width:�,.(4.... Diameter................ Depth�._�_�__..... x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. 3 Seepage Pit No.......I..... ...... Diameter........)b_..... Depth below inlet................ Total leaching area-L.6.7.....sq. ft. z Other Distribution box ( } Dosin tank ( ) I - Percolation Test Results Performed by.. ,�...__AA.(��J�1�.f�rr'��Cls.................. Date......_1 _1..5��. .�._... Test Pit No. I................minutes per inch Depth of Test Pit....��Z.b._t{.__ Depth to ground w ter... . Dt- 44 Test Pit No. 2.:55.'Z _minutes per Inch Depth of Test Pit....142.0..... Depth to ground water................... P4 ............................................................................................ ..... ............. O Description of Soil..................... ...... V ...---•.........................•--•------------•----•-•---•-----------•-----------...------..._.........--•-----------------------------•-••......-•----••---•--.......... ......-----•-•.........-- UW ----•--------------------- -------------•-----•----.........---•-••--------........----............. -------•----------------......•-----------•----•---.............._..................---•--•----.... 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 LI L LZ 5 of the State Sanitary Code— "fhe ndersigned further agrees not to place the system in opera . n unt' a Certificate of Comp iance has b, issued 4bth e oa d of I th. Signed..., Date A plication App oved By----- eu --�—z..................................... ,� J 1 ,�.... Date Application Disapproved for the following reasons:...................................................................................... ..........__ ....-•-•................•---.....------...------......../............................---.....-•---...............--••--•-----•--....-•--•-•-•-----.............------............--- ............ Date PermitNo....... ..................... Issued........................................................ Date •• I J P Ficz THE COM�NWEALTH OF MASSACHUSETTS (,�� b�l' • BOARD OF HEALTH l V t7 ...- U . .... ..- ..1 (..... .....OF..... , G� ��L L , Appliratisn for 14spnsal Workii Tonstrnrtiun jlrrmit(�r'5 r ''Application is hereby made for a Permit to Construct Z><) or Repair ( ) an Individual Sewage Disposal d System at, ...... .__........._..��ation-....... Ad Bess....................................._ ...... .-•----....--•--•----......---or Lot-N .....--•--......................._........ ... iOC�.:�::�.� ........:d 1��__.1.� �.� .....-�'--..-- -. . .... % .;��GS .... Owner 'J [ t .............. ................................................ .... ... W _ ____•______.__. � Installer" _____'A_-A dress ° �... _dr ....q:....... Address Type of Building Size Lot.............................S feet U DwellingNo. of Bedrooms.•____________________________ Ex ansion Attic 'IF," a p ( ) 1 -rv�r Gar age Grinder ( ) aOther—Type'of Building ........................`.. No. of persons........... Shower;•• (tO— Cafeteria ( ) dOther fixtures . ram _..-•----------•----•--• ------------------------------------__----•--- W - Design Flo`w...............11...Ln........... __..gallons-per perm per day. Total daily flow....--r............................:---------gallons. WSeptic Tank—Liquid capacityZe�Ogallons Length... Width L!=../o_... Diameter................ Depth��. .__.... x Disposal Trench—No..................... Width.................... Total Length..........._........ Total leaching area....................sq. ft. 3 Seepage Pit No.......j............ Diameter........ ..... Depth below inlet... "..............Total leaching area.7:6. 7_....sq. ft. Z Other Distribution box (�) Dosing tank aPercolation Test Results Performed by.. .. .....I.A1................... _�: �................... Date........ ...`± Test Pit No. ]................minutes per inch Depth of Test Pit..... Depth to ground water...?.j....1�F _. Test Pit No. 2.�_2._._..minutes per inch Depth of Test Pit.... C!?f�_.._. Depth to ground water.... At C..... WAa .... ................................................................................................................ O Description of Soil ------•-• :. ..._.....-.. W U Nature of Repairs or Alterations—Answer when applicable............................................................................................... ----------•----------------- ........•--------- 4 -Agreement: The undersigned agrees `to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of AITL; 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operan untiVa Certificate of Compliance has-b e^n issued b�y�/t�)�o of health. ` f� Signed__v i_.. .,.�? /.._ /U�r 5�1:5�........ �� Date Application Ap oved By--- x;•.�•... � a t !'"".". ..................................... �l Date Application Disapproved for the following reasons:........................................................................................................... I — 4 Date PermitNo. `r' ------------------- Issued.. ...--•--•------•--•---•-------•-------••-••••-- Date r> THE COMMONWEALTH OF MASSACHUSETTS OA OF `ra�.........8 OFRD...tm:�l-LE [:f•.a'.--......... ............. G (Irrtif irate sf Tnntphatnrr i THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed 0<) or Repaired ( ) by......................... ..........................•-•-....---.--••--•---•-..........._..--------•---•--•---------•-------•--.............................---..............-- A t 1 Insta ler d � fir— /� at_........1` �� l 10.CAA. f. v ,f f! i, FJ ..............................................•-•-•- has been installed in accordance with the provisions of TITL�E 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No...........�r_ !a.�.� . '� dated__..:n. ...................................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. ts,;o DATE.... f.� -.••a v ................................................. Inspector........: ............................................................. C3-C-s�o'o.Vors��ae.oalso e�ma�asons-n.`w+...._.w.��..r«e.r+P?�ri ue-asa-oe-wossos�v�oarYlwaA 4+tm maro @i'�ea?.n.1�..r..r�r..r....dace s.rre�s.e�s-oe�vmai THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ( f.................................. Disposal 10ork.9 Tonstrurtion Vern it, Permission is hereby granted---------... .......................... U ! ►...__ ..�......�-..-:(__J.r..t.!........................... Constructr Repair iva�ewag�Disposai at No......... ......A � � .... Street C� / as shown on the application for Disposal Works Construction Permit No.!�.«:/2,ri . Dated.......................................... •----••._...•-- � _ L� �V oard of Health DATE.................. ---". �,/...._....:........ ..........._..... - J BOARD OF HEALTH TOWN OF BARNSTABLE Yell Con5truction Permit , Nd --�=�---- Fee-- ---- Permission is hereby granted------ ----------------------------------------------------- IN� -------1- -------fie — to Construct (�, Alter ( ), or Repair ( ) an Individu Well at: No. ---------------��1 -- Ig - =- ` - - - Street as shown on the application for a Well Construction Permit No.----- — --------- ------ -- Dated----- 11��= g - ---- - ----- --- ---- - ---- —--------------- --- oard of Health DATE---- ----------------------—---- -- x Department of Environmental Management/Division of Water ResourcesrZ rOr WATER WELL COMPLETION REPORT r WELL LOCATION Address/'_f ,y 1�� tG'rc%' tt J✓ .` , City/Town G.S:Quadrangle.Map t Grid Location 777 0wn6r!' C �r9ALG.1 t. ra/ `��CY7'l�7�`� "t/-o'y`t✓ 7i' ! Address,/x5 WELL USE CONSOLIDATED WELL Domestic 0 Public ❑ Industrial❑ Type of Water-bearing Rock Other Water-bearing Zones Method Drilled r !i`+"C.�t ,.-.' 1) Fran t.>e j ✓ 2) From nTo Date Drilled ICJ/ 5 A; 3)•From - To• ' / 4)-,From To -y CASING o r Depth to Bedrock,' .Length 7 ! Diameter Type UNCONSOLIDATED WELL STATIC WATER LEVEL Water'-bearing Materials Feet below land'surface -�a f Sand:` fine®', medium® coarse❑ Date measured.d.C.L Gravel: fine❑ medium❑ coarse❑ Screen: GRAVEL PACK WELL �/ Slot#%J length 3 from,7 to ! Yes ❑ No !+ Split Screen (or•2ndscreen). WATER QUALITY TESTS MADE Slot# length from' to Chemical ❑ Biological 0 Depth.To Bedrock PUMP TEST 'Drawdown feet after,pumping days hours at' .,GPM. How measured Recovery feet after hours. LOG of FORMATIONS COMMENTS: (On well or water) Materials, From To 10 r#, �cf /S DRILLER I, Firm CI1Or(� )Nell:�UnlEr.2�. o r03 .S— Address X 30 — 5. / ,Id 5.4-a ftil JT 7/.- City �9 '�AI9fl0llt W _. Registration No.' � perators ignature-, Lse pa�rm , .. . BOARD.`OF. HEALTH COPY 15M-2 84 nc4r,' 1► , AQUA-TEST 1653 MAIN STREET PO BOX 526 WEST CHATHAM, MA 02669 TEL 508-945-5895 DEP LABORATORY JMA102 DRINKING WATER LABORATORY ANALYSIS LAB NO. 2453 BOTTLE NO. 215B CLIENT Clifford Well Drilling COLLECTOR Fred Clifford MAILING ADDRESS PO Box 430 DATE & TIME 10/26/89 OF COLLECTION South Yarmouth, MA 02664 TYPE OF SAMPLE Well TELEPHONE 394-6721 WELL DEPTH 40 SAMPLE LOCATION Lot #4 Meadow Lane DATE OF ANALYSIS 10/26/89 W.Barnstable, MA DATE OF REPORT 10/27/89 for: Meadow Lane Realty Trust, 1000 Main St., W.Barnstable, MA ------------------------------------------------------------------------------------- SEE REVERSE SIDE FOR EXPLANATION OF TEST RESULTS = ;; k: PARAMETER SAMPLE RESULTS MASSACHUSETTS RECOM(+ENDED LIMITS TOTAL COLIFORM BACTERIA/100 ML 0 1 PH 5.9 S.B-B.5 rr;, CONDUCTIVITY (MICRCMHOS/CM) 78 500 IRON (MG/L) 0.3 0.3 NITRATE - NITROGEN 0.5 10.0 SOOILn (m/L) 7.8 20.0 REMARKS: LABORATORY DIRECTOR EXPLANATION OF TEST RESULTS TOTAL COLIFORM BACTERIA COLIFORM BACTERIA ARE AN INDICATOR OF THE SANITARY QUALITY OF A WATER SUPPLY. WATER SUPPLIES MAY BECOME CONTAMINATED FROM MALFUNCTIONING SEPTIC SYSTEMS, CESSPOOLS, AND SURFACE RUNOFF. A TOTAL COLIFORM COUNT OF ONE OR LESS INDICATES THAT YOUR WATER SUPPLY IS SAFE TO DRINK. A TOTAL COLIFORM COUNT OF GREATER THAN ONE IS MOST OFTEN THE RESULT OF ACCIDENTAL CONTAMINATION OF THE SAMPLE BOTTLE THROUGH IMPROPER SAMPLING TECHNIQUE. FOR THIS REASON, IT WOULD BE ADVISABLE TO RETEST ANY WELL WATER THAT HAS A COLIFORM BACTERIA COUNT OF GREATER THAN ONE. PH PH IS THE MEASURE OF ACIDITY OR ALKALINITY OF WATER. ON THE PH SCALE, THE NUMBER 7 IS NEUTRAL, .LESS THAN 7 IS ACIDIC AND MORE THAN 7 IS ALKALINE. THE PH OF WATER ON CAPE COD TENDS TO BE IN THE RANGE OF 5.0 TO 6.5. LOW PH MAY SHORTEN THE LIFE OF A HOUSE'S PLUMBING. CONDUCTIVIW CONDUCTIVITY IS A MEASURE OF THE DISSOLVED SALTS IN SOLUTION. AMOUNTS IN EXCESS OF 500 MICROMHOS/CM ARE GENERALLY CONSIDERED UNACCEPTABLE AND MAY PRODUCE A LAXATIVE EFFECT. IRON THE PRESENCE OF IRON IN WATER IN A CONCENTRATION OF 0.3.MG/L OR MORE MAY GIVE THE WATER A BITTERSWEET ASTRINGENT TASTE, AND CAUSE AN UNPLEASANT ODOR. IT OFTEN GIVES THE WATER A BROWNISH COLOR AND CAUSES STAINING OF LAUNDRY AND PORCELAIN. THE AVERAGE CONCENTRATION OF IRON IN CAPE COD'S WATER IS 0.2 TO 0.6 MG/L. ALTHOUGH THE PRESENCE OF IRON IN WATER MAY CAUSE THE PROBLEMS MENTIONED ABOVE, IT IS NOT CONSIDERED DELETERIOUS TO HEALTH. IRON MAY BE REMOVED BY A NUMBER OF DIFFERENT IRON REMOVAL SYSTEMS. NITRATE - NITROGEN THE MASSACHUSETTS DRINKING WATER REGULATIONS HAVE SET A MAXIMUM CONTAMINANT LEVEL FOR NITRATES AT 10 MG/L. EXCESSIVE CONCENTRATIONS MAY CAUSE METHEMOGLOBINEMIA AN INFANT DISEASE AND HAVE BEEN SUGGESTED TO FORM POTENTIALLY CARCINOGENIC NITROSAMINES. CONTAMINATION SOURCES INCLUDE FERTILIZERS, CESSPOOLS AND INDUSTRIAL WASTES. COPPER DUE TO THE ACIDIC NATURE OF THE WATER ON CAPE COD, COPPER TENDS TO LEACH FROM PIPES. THIS NORMALLY DORS NOT PRESENT A HEALTH HAZARD, HOWEVER, CONCENTRATIONS IN EXCESS OF 1.0 MG/L MAY CAUSE R METALLIC TASTE AND/OR A BLUE-GREEN STAIN ON PORCELAIN FIXTURES. SODnm A CONCENTRATION OF SODIUM OVER 20 MG/L MAY BE A CONCERN TO PEOPLE WHO ARE ON A LOW SODIUM DIET. SUCH PERSONS SHOULD CONTACT THEIR DOCTOR TO DETERMINE IF CONSUMING THE WATER IS ADVISABLE. CONCENTRATIONS EXCEEDING 50 MG/L INDICATE THAT THERE MAY BE OCEAN WATER OR ROAD SALT RUNOFF WATER GETTING INTO THE WELL. PLEASE NOTE WATER FROM THE SAME SOURCE CAN PRODUCE DIFFERING RESULTS IF TESTED AT DIFFERENT TIMES AND/OR DIFFERENT LOCATIONS. BARNSTABLE COUNTY HEALTH AND ENVIRONMENTAL DEPARTMENT �4 SUPERIOR COURT HOUSE O BARNSTABLE. MASSACHUSETTS 02630 J o • �A SS PHONE:362-2511 EXT.337 SAMPLING INSTRUCTIONS FOR PRIVATE WELLS An improperly taken sample wastes your money and has neither scientific accuracy nor legal acceptance. 1. Obtain sterile sampling bottle from the County Lab or Town Health Department. Bottles sterilized at home are not acceptable. 2. Remove strainer or aerator from the end of the faucet, preferably NOT swingtype. 3. Turn on the cold water and let it run for five (5) minutes. 4. Fill the bottle leaving a one inch air space. Do not fill the bottle to the top. Be careful not to touch the inside of the bottle or cap with the faucet, your hands, or anything else. 5. Fill out the reverse side. The laboratory requires accurate and complete information. The person filling the bottle must sign the form.. 6. The charge for a routine well analysis (coliform bacteria, pH, conductivity, iron, and nitrate) is $25.00. Checks should be made payable to Barnstable County. Exact change is required if paying in cash. Additional tests require additional fees. Consult lab or a price list for exact information. 7. Samples are accepted .Monday-Thursday from 8:00 to 1 :00 • They must be delivered to the lab within 6 hours of collection or 24 hours if refrigerated. 8. Please be prepared to locate the house on the maps at the laboratory. 9. Problems with town waters must be handled through the town water departments. 10. Completion of tests and results takes 2-3 days. Results will be sent in the mail. NOTICE : WATER FROM THE SArIT] SOURCE CAN PRODUCE CONTRARY RESULTS IF TESTED AT DIFFERENT TIMES AND/OR DIFFERENT LOCATIONS . THE COUNTY OF BARNSTABLE SHALL NOT BE LIABLE FOR DANIAOES RESULTING, FROM THE RELIANCE ON RESULTS OF F7ATER TESTS ACCURATELY DEP.FORfIED. PLEASE COMPLETE REVERSE SIDE OF FORM LOG NO. PLEASE READ INSTRUCTIONS ON REVERSE SIDE BEFORE COMPLETING THIS FORM (for Lab use) BARNSTABLE COUNTY HEALTH AND ENVIRONMENTAL DEPARTMENT 362-2511 X 337 DRINKING WATER ANALYSIS LABORATORY SHEET Name Sampling Date: Time: Mailing Address: Sample Location: (street or box) (street) Zip (town/city) . (state) (town) Telephone: Year House Was Built: Bottle Identification Number Well Depth Ft. (taken from bottle) Reason for testing (check one) : ( ) suspect a problem ( ) required by DEQE ( ) for information only ( ) new well ( ) real estate transaction*. ( ) other *Note: Some banks and mortgage companies may require additional testing which costs more and requires more water. Check with Lab before bringing in the sample. istance of supply from possible contamination sources (check all that apply) : ( ) septic tank/cesspool Ft. ( ) farm Ft. ( ) salted highway Ft. ( ) other Ft. ( ) landfill Ft. ( ) buried fuel tank Ft. Treatment used: ( ) none ( ) water softener ( ) filter SIGNATURE OF SAMPLE COLLECTOR: ( ) Well Driller ( ) Owner ( ) Realtor ( ) Tenant ( ) Other - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - FOR LAB USE - Total Coliform/100 ml PH Conductivity (micromhos/cm) Iron (ppm) Nitrate-Nitrogen (ppm) Sodium (ppm) Y 502 . 2 or 524 . 1 or 524 . 2 . These tests include analyses for purgeable halocarbons and purgeable aromatics , as well as analyses for petroleum hydrocarbons or pesticides . 2) ; The Board of Health will determine potability of the well water using as guidelines the National Interim Primary and Secondary Drinking Water Standards water qualityhe . S . EPA Maximum Contaminant Levels (MCLs) . The standards for common parameters are as follows : Primary Standards Total Coliform 0 colonies/100 ml . MF Nitrate 10 ppm Secondary Standards PH recommend pH above 6 . 0 Sodium 20 ppm Iron 0 . 3 ppm 3) When the Board of Health deems it necessary, t}ie Health Agent; or other agent of o fthea. waterd of Health may sample and/or may take tent he to witness the taking water sample and deliver it to the testing laboratory him/Herself. 4) The Board of Health further recommends that all well owners have their wells tested at a minimum of every two ( 2) years , and at more frequent intervals when water quality problems are known to exist. 12_ RUIN. LU L2 ANTI HATER ala= (S IGN 1) Before ' approval , every well shall be pump tested to determine yield . The pump test shall include a drawdown test at a minimum pumping rate of 5 gallons per minute for one ( 1 ) hour. of the water system, including well , pump, 2) The design uate to storage tank , and other accessories ust ,minute which equals provide a water capacity in gallons Per tile. number (-)f water fixtures installed; in addition , capacity ( in gpm) must not be less than the peak demand for the largest fixture installed. For the purposes of this regulation a fixture is defined as a water outlet, and includes faucets , sinks , toilets , bathtubs , washing machines , dishwashers , and the like. BARNSTABLE COUNTY HEALTH AND ENVIRONMENTAL DEPARTMENT z ��' SUPERIOR COURT HOUSE BARNSTABLE, MASSACHUSETTS 02630 o � o � PHONE: 362-2511 t EXV330 VOLATI LE ORGAtIIC COt�1P0UtIUS REPORT LAD 337 ---- -- '- CLINIC 340 Client: Clifford Well Drilling Collector: S . O ' Brien Mailing Address: P . O . Box 430 Type Supply: yp of pp y. Private S . Yarmouth MA 02664 Date Collected: 11 /3/89 Telephone: 394-6721 Date Received: 11 /3/89 Sample Location: Lot #4 Meadow Ln . Analyst: E . Butler W . Ba.rnstable Date Analyzed: 1.1 /6/89 LOCAT1011 Lot #4 Meadow COMPOUtID ppb Lane . W . Barnstable Chloroform 1 . 7 cc : Barnstable B and of Health All values are in micrograms per liter (equivalent to parts per billion, or ppb) . EPA Method 502.1 was used and only those compounds listed above were detected. Attached is a list 'of chemicals which the method is capable of detecting. Detection limits for these compounds are stated on the attachment. Chloroform is commonly found in Cape Cod groundwater at levels ranging from 0.2 to several ppb. The drinking water limit for Total Trihalomethanes, of which chloroform is an example , is 100 ppb. B.j _t of BARNSTABLE COUNTY HEALTH AND ENVIRONMENTAL DEPARTMENT SUPERIOR COURT HOUSE v P7 BARNSTABLE, MASSACHUSETTS 02630 C TABLE 1. Compounds Detectable by EPA Method 502.1* P HONE: 362.2511 EXT. 330 LAB 337 COMPOUND D.L. COMPOUND D.L. CLINIC 340 Benzene 0.5 1 ,1-Dichloroethane 0.5 Carbontetrachloride 0.5 1 ,1-Dichloropropene 0.5 1 ,1-Dichloroethylene 0.5 1 ,3-Dichloropropene 0.5 1 ,2-Dichloroethane 0.5 1 ,2-Dichloropropane 0.5 para Dichlorobenzene' 0.5 1 ,3-Dichloropropane 0.5 Trichloroe.thylene 0.5 2,2-Dichloropropane 0.5 1 ,1 ,1-Trichloroethane-- 0.5 Ethylbenzene 0.5 Vinyl Chloride 0.5 Styrene 0.5 Bromobenzene 0.5 1 ,1 ,2-Trichloroethane 0.5 Bromodichloromethane 0.5 1 ,1 ,1 ,2-Tetrachloroethane 0.5 Bromoform 0.5 1 ,1 ,2,2-Tetrachloroethane 0.5 Bromomethane 0.5 Tetrachloroethylene 0.5 Chlorobenzene 0.5 1 ,2 ,3-Trichloropropane 0.5 Chlorodibromomethane 0.5 Toluene 0.5 Chloroethane 0.5 para Xylene 0.5 Chloroform 0.5 ortho Xylene 0.5 Chlo.romethane 0.5 meta Xylene 0.5 ortho Chlorotoluene 0.5 Bromochloromethane 0.5 para Chlorotoluene 0.5 . Dichlorodifluoromethane 0.5 Dibromomethane 0.5 Fluorotrichloromethane 0.5 meta Dichlorobenzene 0.5 Hexachlorobutadiene 0.5 ortho Dichlorobenzene 0.5 Isopropylbenzene 0.5 trans-1 ,2 Dichloroethylene 0.5 n-Propylbenzene 0.5 cis-1 ,2 Dichloroethylene 0.5 Sec-butylbenzene 0.5 Dichloromethane 0.5 Tert-butylbenzene 0.5 D.L. is Detection Limit in micrograms per liter or parts per billion (ppb) . This table lists- our normal limits of detection. If we report a smaller amount, then our detection limit was lower. for that analysis. *A photoionization detector is used in series with the electroconductivity -detector, thus allowing for the analysis of most of the compounds listed in EPA Method 503.1 as well . TABLE 2. Compounds which have Maximum Contaminant Levels (MCLs) set by the Environmental Protection Agency. 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