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Home My WebLink About0145 MEADOW LANE - Health 145 Meadow Lane West Barnstable A= 134-021 Commonwealth of Massachusetts H v Title 5 Official Inspection For ' Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Ae '-1 clo V Z—ci 1-1-e- Property Address � / ei V �"i / _c Owner Owner's Name information is I / required for every �s ��/✓►S�uJ�2 V//� page. City/Town State Zip Code Date of I spection 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 f A. General Information filling out forms 5/4 1 a s 91 on the computer, use only the tab 1. Inspector: key move your cursor-do no, use the return G "► O key. Name of Inspector Company Name 2 Company Address s4 1�4 61:) ��z City[Town State 4f — — - /[0 Zip Code Telephone Number o C/ 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(31 MR 15.000).The system: Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority jInspects Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original 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.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 �,oe VS Cornrnonwealth Of Massachusetts Title 5 Official Inspection For Subsurface Sewage Disposal System Form)-Not for Voluntary Assessments Property Address �N Owner �o5-¢Pr Owner's Name ! n information is IW/ S 11 // required for every 2S G/d1 S7� 1'1�¢page. City,I own Zip State Cde / o Date of In pection B. Certification (Cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System P ses: I have not fou nd 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: ❑ 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.doc•rev.6116 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 ^� r Property Address �� Owner s ✓ information is Owner's Name / • required for every O�6� Ciry/Town 6� State Zip Code Date of nspE,ction Bo Certification (Cont.) page. ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if Pumps/alarms are repaired. B) System Conditionally Lasses (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 I:o determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 15ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 r Commonwealth of Massachusetts Title 5 Official Ins pecti®n F®r Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M ��/^r � / Property Address e cio I �` Owner Owner's Name rS information is / �� required for every page. City/Town State Zip Code Date f If snoDate pection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public water Supplier-, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the S/ S 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 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 v� g o faculty or system component due to overloaded or clogged SAS or cesspool ❑ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ®/ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool Liquid depth in cesspool is less than 6"below invert or available volume is less than day flow l5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection For Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M �l Property Address � L,-� Z /� Owner Owner's Name information is 9 / required for every (i✓�S �g�✓IS��b/e -1'�1 D� 6 6 O / (o page. City/Town State Zip Code Date of In B. Certification (cont.) pection Yes No Required pumping more than 4 times in the last year IVOY due to clogged or ❑ obstructed pipe(s). Number of times pumped: ❑ Any portion of the SAS, cesspool or privy is below g high gr ound ounci water elevation. ❑ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ L"�1/ Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ Any portion of a cesspool or privy is p y within 50 feet of a private water supply well. ❑ Any portion of a cesspool or privy is p y 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 forma ❑ The system is a cesspool serving a facility with a design flow of 2000gpd- 10,0009pd. ❑ 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection For Subsurface Sewage/ /ten)Disposal System Form - Not for Voluntary Assessments //--/.,f,.. 4 M / SyOY`'V !!// / Property Address // '/,q CO t,/ Owner Owner's Name information is required for every page. City/Town ��/`►S7'�L / //J �� 6 (�d // State Zip Code Date Ins ection C. Checklist Check if the following have been done. You must indicate "yes"or"no"as to each of the following: Yes o ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ Were any of the system components pumped out in the previous two weeks? ❑ Has the system received normal flows in the previous two week period? ❑ Have large volumes of water been introduced to the system recently or as part of this inspection? Were as built plans of the system obtained and examined? (If they were not available note as N/A) Was the facility or dwelling inspected for signs of sewage back up? >E1 Was the site inspected for signs of break out? ❑ Were all system components, excluding the SAS, located on site? ❑ Were the septic tank manholes uncove red, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ��❑ Existing information. For example, a plan at the Board of Health. ❑ Determined in the field (if any of the failure criteria related to Part C Is at Issue approximation of distance is unacceptable) [310 CMR 15.302(5)] Do System Information Residential Flow Conditions: Number of bedrooms (design):g ) Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): t5ins.doc•rev.6/16 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 +C Wa rroperty Address /I/�- M le Owner Owner's Name ��sTP� information is required for every /d1S�� Page City"own / State Zip Code Date of nsp ctio ®. System Ind®rmati®n Description: ��/11 f41,s11 _/7o17 4 Number of current residents: c), Does residence have a garbage grinder? Is laundry on a separate sewage system? ❑ Yes No g y (Include laundry system inspection information in this report.) ❑ Yes No Laundry system inspected? ❑ Yes Seasonal use? ❑ Yes No Water meter readings, if available (last 2 years usage (gpd)): Detail: . Sump pump? ❑ Yes No Last date of occupancy: C ui lne,- 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 I Comirnonvvealth of Massachusetts Title 5 Official Inspect- Ion Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address 7 �- �l C"oL./ Owner p�wn r's Name 05"�'e information is �"� —/required for every G/�S4u/�e /X j �1 f/.� page. City/Town o �J of b l� / State Zip Code Date of spa tion Do System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: �� — ®�� ap-- Was system pumped as part of the inspection? ❑ Yes No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of stem: 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 - I , COMMonwealth of Massachusetts N _ Title 5 Official Insp or Voluntary Subsurface Sewage Disposal System Form - Not f ®r V ntary Assessments Property Address / / Ci r o C.1/ .4- 4 Owner Owner's Nam Foss e information is l / required for every -P S�— rtat page. City/Town Zip Code Date of I spect on Do System Information (Cont. Approximate age of all components, date installed if known)and Wurce of information: Were sewage odors detected when arriving at the site? ❑ Yes No Building Sewer(locate on site plan): / Depth below grade: /O feet Material of constructi;4--0 ❑ cast iron PVC _ ❑ other(explain): Distance from private water supply well or suction line: 7L feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: feet Material construction: concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificcaate) El Yes El No J Dimensions: >/- E Sludge depth: /r l t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 F COMMonwealth of Massachusetts Title 5 Official Inspection / Subsurface Sewage Disposal System Form -Not for Voluntary ry Assessments rl operty Address -�p `�t✓ Owner Owner's Name / JS information is /required for every 2S4- page. City/Town c'/`� a Wnsction State Zip Code Date o ® System 9nf®rmata®n (cont.) Septic Tank(cont.) 2 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? 7-, 1 a Comments (on pumping recommendations, inlet and outlet tee or baffle condition, tructural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): ^N _" Ci"t) - � Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑ metal ❑fiberglass g El 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 t5ins.doc-rev.6/16 Date of last pumping: _ Date Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner l O S-7�tr information is Owner's Name required for every v'� �S J y�✓]S�u�j/� //%� (�a_ 6 page. City/Town State Zip Code Date of sp tion 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: El concrete El 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 I COMMonwealth of Massachusetts Title 5 Official I - Subsurface Sewage Disposal System ®r y m Not for Voluntary Assessments Property Address �'C'O t. Owner Owner's Name OS )¢//'` information is required for everyS/� 0-1 6 61 page. Clty/Town State Zip Code Date of Ins ction D. System Information (cont.) Distribution Sox(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert / / zje/' � 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.): O / /V So/, �f 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.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 COMMonwealth of Massachusetts °Title 5 Official Inspection For Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address ///��`i c'i7l✓ �---�V Owner Owner's Name oS e� information is required for every ":— ,,_ G✓�sT �� /� b 6� / page. City/Town D. System Inf®rmati State Zip Code Date o In ection on (coot.) Type. f 7—s��ll-rr� 4olf ��j�Jv� // ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Cx- `o 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.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Insp ace ection Form®r Se wage Di sposal system Form -Not for Voluntary Assessments 1M Property Address Owner Owner---s N — pY• information is required for every page. City/Town - -- � State Zip C Date of nsp coon De System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 I Commonwealth of Massachusetts W� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments /-Z r Property Address Owner information is Owner's Name//L/ � required for every l// S cr�✓7s a�j //�� b(� 9 l�j page. City/Town -Code Zip Code Date Ins ection ®a System Information (coot.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate wh>hand-sketch u 'c water supply enters the building. Check one of the boxes below:in the area below Eldrawing attached separately I N S F/RuNY- \�y �--- v 0 Z S�pftc r-- oUt S�Yt svt'7t�a// t� �o 1 t5ins.doc•rev.6116 Title 5 Official Inspection Form;Subsurface Sewage Disposal System•Page 15 of 17 I Commonwealth of Massachusetts Title 5 official Inspection For Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M /��s /AP Property Address Owner Sv Owner's Name information is required for every -es T �a��✓r 5 �� /�� G / page. City/Town State Zip Code Date f In ection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells A-V pie Estimated depth to high ground water: T 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 ❑ erved site (abutting property/observation hole within 150 feet of SAS) Checked with loc oard of Health -explain: �Gj4 7--es- / "O4 opt ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must descr Is hpy�you established the high ground water elevation: S: A _� � S % o _- - - --- �S - - _QL, _ -- 5` Before filing this Inspection Report, please see Report Completeness Checklist on next page. l5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 T Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner Owne�Name information is / /�S required for every (it/ T Gigs ��L6 �� / page. City/Town State Zip Code Date of nsp tion E. Report Completeness Checklist ----:---------------- Inspection Summary; A, B, C, D, or E checked Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ;/Sketch tem Information— Estimated depth to high groundwater f o Sewage Disposal System either drawn on page 15 or attached in separate file t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 TOWN OF BAMSTABLE LOCATION 11Cr MI:I' O4C1 z4A1C SEWAGE # VILLAGE w, ASSESSOR'S/MAP & LOT15q—V INSTALLER'S NAME&PHONE NO. 09- Y24-y70 JfSCf°�i �J�131�G�S SEPTIC TANK CAPACITY /6V0 LEACHING FACILITY: (type) L/ H7d y'lF�7Y6�1( tie �� X YG NO. OF BEDROOMS 2 �� '.I 3dn f-p / BUILDER OR OWNER _,0Qa0- �S 1/ OL r PERMIT DATE: COMPLIANCE DATE: 7"2 8 m 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 leachingfacility) Feet Furnished by�_ K o � s v o �044 ZviS'pFcTion port No. � '— � Fee oo THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 0[ppYication for 30igozal *patent Construction permit Application for a Permit to Construct(lXRepair(grade( ) Abandon( ) ❑ Complete System U Individual Components Location Address or Lot No. dC!/ 19H� le f'LJ�14 Owner's Name,Address,And Tel.No. ,,s' "/I ,0.4ryt�,b/�- Gor�s'T��cc ,por,�q/ems fr'oLr' Assessor's Map/Parcel Installer's Name,Address,and Tel.No. �$' 280_ S� Designer's Name,Address and Tel.No. JOScpk V1 Qp�/^rl7S �cvc eT'S er' /;hc�idle�/�i�� Type of Building: Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder ( ) Other Type of Building No.of Persons Sowers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil a Nature of Repairs or Alterations(Answer when applicable) 41 �� C'7tzl9G lT� Y`l Fri` Tote's 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 unti a Certificate of Compliance has been issued by this Board of Health. Sign Date A lication Approved b pp PP y W, Date / e Application Disapproved b Date for the following reasons Permit No. a0 /o Date Issued o o , At' 3 : Fee THE COMMONWEALTH OF viASSACHUSETTS Entered in computer: VVI ,'PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes ZIpprication for Migoar 6paem Couttructiou Permit Application for a Permit to Construct(�,KRepair(yam Upgrade( ) Abandon( ) ❑Complete System U Individual Components Location Address or Lot No./%r �,We_14d& / G i9H,; Owner's Name,Address,and Tel.No. M Assessor's Map/Parcel 3 y_ 1/ ..Sqx_lvF -`1752 Installer's Name,Address,and Tel.No.,�� z80 Designer's Name,Address and Tel.No. .�U�' Type of Building: Dwelling No.of Bedrooms '3 Lot Size sq. ft. Garbage Grinder ( ) Other Type of Building No.of Persons Showers Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided N gpd Plan Date Number of sheets Revision Date' Title Size of Septic Tank Type of S.A.S. Description of Soil 0y 4 , Nature of lRepairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage,disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation untill a Certificate of Compliance has been issued by this Board of Health. / Sign Date Application Approved by 1 Date Application Disapproved b : Date T for the following reasons Permit No. )0 t o oZ Date Issued 2 u - THE COMMONWEALTH OF MASSACHUSETTS t BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired ( ca Upgraded ( � ) Abandoned( )by OP5 if at /y 5- �Ji_�q� u/ `j..r. has been constructed in accordance with the provisions of l/-Tittle?5 and the for Disposal System Construction Permit No. 6/o- o� �/ dated Installer /15 C i0 Li a �i�`"y'!J S Designers #bedrooms 3 Approved design flow,l _3,�U gpd The issuance of t -s pernut shall not be construed as a guarantee that the system D ct:io as designed. Date o Inspector / " 1 I47 No. Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION — BARNSTABLE, MASSACHUSETTS / a &5po5al *pttem Cou5tructiou Permit Permission is hereby granted to Construct (/j) Repair ( G•)- Upgrade ( ) Abandon ( ) System located at yg' �tir4r p� Sr/'i%f--- and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title S and the following local provisions or special conditions. Provided: Construction must be completed within three years of the date of this :e .. Date �� h V APProveci byr' ✓, -.4L 3�P �p v srrr, p I f or 5 r Town of Barnstable Regulatory Services Thomas F. Geiler,Director w MAE& 1ABNSTABI.E. p Public Health Division Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer&Designer Certification Form Date: 'J b Sewage Permit# N q 7 Assessor's Map\Parcel 43 CC Designer: J�t"J , e,,4nal t) Installer: Address: P,d . 7 13 Address: P 0J—&X cl od&66 On 7 02 O � s Se ` t (- was issued a permit to install a (date) (installer) septic system at q4?6 J4LJ k6 tlP W based on a design drawn by (address) 4 dated ( 7 (des' er) I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. F I certify that the septic system referenced above was installed with major changes (i.e., CD greater than 10' lateral relocation of the SAS or any vertical relocation of any component-:) of the septic system) but.in accordance,with State&Local Regulat' Plan revision or._ certified as-built by designer to follow. H of M . DUMAS (Installer's Signature) `I�' No.619 OfBTER�O AW I SgNf T (Designer's Signature) / J . (Affix Designer's Stamp Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE :ISSUED UNTIL BOTH THIS FORM AND AS-BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q:Health/Sept,signer Certification Form 3-26-04.doc i v rr AA VA i1111111A.QAAIV Y# 12 9 7D Department of Health,Safety,.and.-Environmental Services ! Public Healtl,Division Date 5' nZ£f (Q aa)M Main Street,Hyannis MA 02601 BARMABLA t Date Scheduled J ✓/tee 1 02 Uf/� Time y Fee Pd. `2) 6d Soil Suitability Assessment for Sewage isposal Performed By: Witnessed By: lies Location Address , .......................:.:.::..:::::.::::::::::: Owner's Name l -U5l4stCah5f-�nCe W2Sf &zAos16_(b1e Address f SGi.YLt� Assessor's Map/Parcel: /3 y o2 t Engineer's.Name �j(v S�o—�/t�l,�fr1C�C%�/✓� .... .. _........._. _ NEW CONSTRUCTION REPAIR Telephone# Land Use ��Ur✓ /17 Slopes(%) O Surface Stones �G / y / Distances from: Open Water Body ft Possible Wet Area / fZ0 ft Drinking Water Well �g Drainage Way ft Property Line Zd� ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) S� Loi 3 a 35 :Sf. • P CO Parent material(geologic) O�T/J4S� lr��fc/� Depth to Bedrock Depth to Groundwater: StandingWater in Hole: Weeping from Pit Face. 1 03 Estimated Seasonal High Groundwater ,S ra ....................:.::::.:::::::::::::::::::::::::.::::,::.;;:;;:::::::::::..:::::::::::;:.;;:.;:;::::::::::.::.::::::.::..:: � Misr 1 r .:::•:::::..::;«:•:;.>:;;<: Method Used: Depth Observed standing in obs.hole: in. Depth to soil mottles: in. Depth to weeping from side of obs.hole: in. Groundwater Adjustment ft. Index Well#_ Rending Date: __ Jndex Well level Adj.factor_ Adj.Groundwater Level Observation Hole# • Time,at=9" Depth of Perc Time at 6" Start Pre-soak Time® Tithe(9"-61) End Pre-soak Rate Min./Inch Site Suitability Assessment: Site Passed _ Site Failed: Additional Testing Needed(Y/N) Original: Public Health Division Observation Hole Data To Be Completed on Back-----� Copy: Applicant s: a WAM •Depth'from Soil Horizon Soil Texture Soil Color , Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes:' Consistency.° I M. I Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell)_ Mottling (Structure,Stones,Boulderes. 0 z Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. o Gravel) 0x i;i% iii'i ;'::%;i Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Mansell) Mottling I(Structure,Stones,Boulderes. % g Flood InsurangeteMan: Above 500 year flood boundary No Yes Within 500 year boundary; No v Yes Within 100 year flood boundary. No Yes Depth_of Naturally Qccurrin�Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? _ If not,what is the depth of naturally occurring pervious material? Certification I certify that on ( (date)I have passed the soil evaluator examination approved by the Department of Environmeritq'Protection and that the ab analysis was performed by me consistent with the required tra• ,ex isean�xperien de • e • 310 CMR 15.017. Signature Date v SWEETSER' ENGINEER° NG 203 SETUCKET ROAD—P.O.BOX 713—SOUTH DENNIS—MASSACHUSETTS 02660 TEL(508)385-6900 FAX(508) 385-6991 LAND SURVEYING—ENGINEERING—TITLE 5 SEPTIC SYSTEMS SEPTIC DESIGN PROPOSAL PAGE 2 . PROPERTY SURVEY AND FLOOR PLAN SKETCH Please fill out this form,includine the:floor.vim sketch,and return to us with the signed proposal and retainer. This information is necessary to properly prepare your Septic System Design. IF YOU ARE PLANNING AN ADDITION PLEASE INCLUDE THAT INFORMATION ALONG WITH THE FOUNDATION DBUNSIONS AND LOCATION FOR THE NEW ADDITION. Total#of Rooms Year Round Home Seasonal Home Owner Occupied Rental #Bedrooms Family Room/Den LivingRoom kj�&�bining Room J_#Bathrooms _-�,ZWasher/Dryer 'V Dishwasher Garbage Disposal Gas Service Town Water In-ground Electric Wires* In-Ground Oil Tank* In-ground Sprinkler* In-ground Gas PipesP7 Please note on sketch where located. Sweetser Engineering assumes no responsibility if in-ground components are damaged,during Soil Testings,Inspections,Locations of and/or Installation of New Septic System. Cellar: V Full Partial(Crawl) Slab Wells: Main Use Irrigation Only (please provide location of all wells) f PLEASE USE THE SPACE BELOW AND THE BACK OF THIS SHEET TO PROVIDE US WITH A ROUGH SKETCH OF THEEXISTING FI.+OOR_PLAN(ALL FLOORS). Also include any items that should be avoided,I�'FEAR' °E,i.e.shrubs, a trees;patios;electnc�lines,tanks,etc. I } a 1 .j :ail y �F j i u 1 � Q 0 1 -5n� T V BOO` G (FOR c 1 `\ CLi �R� b v a t TRANS. NO.: CITY/TOWN: W e-t,-4— Rja-.rox 5-E-" (e, APPLICANT: ( - ADDRESS: I 5 �U\e-a-do DESIGN FLOW: gpd REVIEWED BY: DATE: N/A OIL NO Legal boundaries denoted [310 CMR 15.220(4)(a)] Street, Lot,tax parcel number and lot number noted on plan [310 / CMR 15.220(4)(u)] Locus Provided [310 CMR 15.2204(t)] Plan proper scale? (1"=40' for plot plans, 1"=20' or fewer for components) 1310 CMR 15.220(4)] Easements shown [310 CMR 15.220(4)(b)] System located totally on lot served [310 CMR 15.405(1)(a) for upgrades]- if not, a variance is required [310 CMR 15.412(4)] Location of impervious surfaces (driveways,parking areas etc.) [310 CMR 15.220(4)(d)] Location all buildings existing and proposed 310 CMR 15.220(4)(c)] Location and dimensions of system components and reserve areas. [310 CMR 15.220(4)(e)] ✓ System Calculations [310 CMR 15.220(4)(0] daily flow septic tank capacity(required andprovided) soil absorption system(required andprovided) whether system designed for garbage'grinder North arrow [310 CMR 15.220(4)(g)] Existing and proposed contours [310 CMR 15.220(4)(g)] Location and log of deep observation holes (existing grade el. on ✓ each test) [310 CMR 15.220(4)(h)] Names of soil evaluator and BOH representative [310 CMR 15.220(4)(h) and(i)] Location and date of percolation tests(performed at proper / elevation?) [310 CMR 15.220(4)(i)] Percolation test results match loading rate? [310 CMR 15.242] Certification statement by Soil Evaluator [310 CMR 15.220(4)0)] Observed and Adjusted groundwater(method for adjustment / given or indicated) [310 CMR 15.103(3) and 310 CMR 15.220(4)(n)] Address ( �� `'`� �/ Sheet 1 of 7 r > y N/A OK NO Location of every water supply,public and private, [310 .CMR 15.220(4)(k)] within 400 feet of the proposed system location in the case / of surface water supplies and gravel packed public water supply within 250 feet of the proposed system location in the case V . . within 150 feet of the proposed system location in the case J of private water supply wells ✓ Location of all surface waters and wetlands located up to 100 ft. beyond setbacks listed in 310 CMR 15.211 and any catch basins located within 50 ft. [310 CMR 15.220(4)(1)] Water lines and other subsurface utilities located [310 CMR 15.220(4)(m)] (if water line cross see 310 CMR 15.211(1)[1]) Profile of system showing invert elevations of all system ,/ components and the bottom of the SAS [310 CMR15.220(4)(o)] Stamp of designer [310 CMR 15.220(1) and 310 CMR 15.220(2)] Stamp of Registered Land Surveyor(required if construction activities within 5 ft. of lot line) [310 CMR 15.220(3)] Test Holes adequate (two in each of the primary'and reserve unless trenches as permitted in 310 CMR 15.102(2) or as approved for an upgrade under LUA at 310 CMR.15.405(1)(k)] Test hole adequate to demonstrate four feet of suitable material. [310 CMR 15.103(4)] Test Holes adequate to confirm adequate groundwater separation? ✓ [310 CMR 15.103(3)] Benchmark within 50-75' of system [310 CMR 15.220(4)( ] Materials specifications noted? [various sections of 310 CMR 15.000] System components not>36" deep (unless Local Upgrade Approval or LUA requested) [310 CMR 15.405(1-(b)] . II Address Sheet 2 of 7 N/A OK NO Size OK? [310 CMR 15.223(1)] Inlet tee located ten-inches.4below-flow line:[3.1.0.CMR 15.227(6)] Outlet tee 14" or 14" + 5" per foot for increase ft`depth [310 CMR 15.227(6)] Outlet tee with gas baffle or approved filter-[310 CMR 15.227(4)] Note regarding installation on stable compacted base [310 CMR 15.228(1)] Separation between inlet and outlet tees (no less than liquid / depth) [310 CMR 15.227(2)] v Inlet/Outlet elevations at least 12" above high groundwater (except as described 310 CNIR 15.227(5)).or permitted for upgrades under LUA [310 CMR 15.405(1)(k)] Minimum cover 9" (Tanks buried more than 9" must have risers / on all openings and on the d-box) [310 CMR 15.2228(1)and 310 CMR 15.232(3)(01 Three access covers (inlet and outlet must be 20" or greater) - middle access at least 8" (by 7/07) [310 CMR 15.228(2)] �G%X f Access to within 6 " of grade - one.port for systems<1000gpd, two for systems>1000 gpd [310 CMR 15.228(2)] All at-grade covers secured to unauthorized access? [310 CMR 15.228(2)] > 10 ft from building foundation [310 CMR 1,5.211(1)] Buoyancy calculation Required/Done [310 CMR 15:221(8)] H-20 Where appropriate?'[310 CMR 15.226(3)] Setbacks from resources [310 CMR 15.211] I, MWIN WE BE Required when other than single-family dwelling or flow>1000 d [310 CMR 15.223(1)(b)] ✓ First compartment 200%.daily flow; Second compartment 100% / daily flow [310 CMR 15.224(2) and(3)] r� "U" pipe through or over.baffle, outlet of each compartment with gas baffle or approved filter [310 CMR 15.224(4)] Address /�U�.��✓, Sheet 3 of 7 1 i N/A OK NO �#� MNW I Located at least ten feet from any water line? [310 CMR 15.222(2)] Disposal piping at least 18" below waterline(when water and sewer cross, see 310 CMR 15.211(1)[1]) Cleanouts re uired/ tovided? [310 CMR 15.222(8)] Thrust blocks specified in force mains? 310 CMR 15.221(6)(c)] Slope of sewer line not less than 0.01 (1/8"/ft) 0.02 preferable [310 CMR 15.222(6)] Proper pitch on all runs? (.005 within gravity-distributed trenches ✓ and beds) [310 CMR 15.251(9) and 310 CMR 15.252(2)(c)] Siphonproblem/ (leachfield below pump chamber) Endca s or vent manifoldspecified? Size and orientation of discharge holes specified? (not smaller / than 3/8" not larger than 5/8") [310 CMR 15.251(8) and 310 !/ CMR 15.252(2)(h)] Materials specified (310 CMR 15.251'(5) specifies various pipe types allowed) Stable compacted base [310 CMR 15.221(2) and 310 CMR 15.232(2)(a)] ; Splash plate or baffle tee required on inlet/provided? (when pressure sewer to d-box or steep pitch of gravity sewer) [310 CMR 15.323(3)(a)] Riser if deeper than 9", [310 CMR 15.232(3)(f)] Inside minimum dimension 12" [310 CMR 15.232(2)(b)] Minimum sum 6" [310 CMR15.232(3)(e)] Watertight cover if<2000gpd); Waterproof manhole if>2000gpd [310 CMR 15.232(3)(d)] Capacity(emergency storage above working--design flow)? [310 CMR 231(2)] f/ Proper setbacks [310 CMR 15.211 (same as septic tanks)] Watertight 20-in minium access manhole at least 20" MUST BE / TO GRADE [310 CMR 15.231(5)] (/ Service components accessible (not too deep with piping, disconnects accessible) Alarm floats - alarm on circuit separate from pumps specified? Exceeds two units must have two pumps operating in lead-lag mode. [310 CMR 15.231(6) and(8)] Stable Compacted Base [310 CMR 15.221(2)] Buoyancy calculations needed? Provided? [310 CMR 15.221(8)] Address Sheet 4 of 7 4 N/A OK NO Calculations correct? 4 feet of_naturally occurring material demonstrated? [310 CMR 15.240(1)] Required separation to groundwater? [310 CMR 15.212)] Aggregatespecified as double washed [310 CMR 15.247(2)] System Venting required/provided? (system under driveway or / >36" deep) [310 CMR 15.241] Inspection ports specified and within 3"final grade? [310 CMR ✓ 15.240(13)] Breakout requirements met? (No violation of breakout elevation / within 15 ft of SAS unless barrier) [310 CMR 15.211(1)[4] and Guidance Document] Chambers and Gal. in trench configuration supplied with inlet every 20 ft. [310 CMR 15.253(6)] Each structure with one inspection manhole(if>2000 gpd must ✓ be to grade) [310 CMR 15.253(2)] Aggregate 1'minimum- 4'maximum. [310 CMR 15.253(l) )] 2' sidewall credit maximum[310 CMR.1.5.253(1)(a)] In bed configuration, inlet every 40 s . ft. [310 CMR 15.253(6)] Width 2'minimum 3'maxunurn4310 CMR 15.251 1 `(b) 100 feet-maximum length [310 CMR`l 5.25.l(T)(a)]' Minimum separation 2x effective depth or width whichever greater(3x if reserve between trenches) [310 CMR 251(1)(d)] Situated along contours..[3 10 0&15,251(2)] Breakout OK?,[310 CMR 15.211(l)[4] and Guidance Document] minimum 2 distribution lines [310 CMR45.152(2)( ' Maximum separation between lines 6' [310 CM R15.252(2)(d)] Maximum separation between lines and outside of bed 4' [310 CMR 15.252(2)(e)] Aggregate depth below discharge pipes 6" minimum, 12" maximum. [310 CMR 15.252(2)(g)] l� Separation between beds 10'minimum. [310 CMR 15.252(2)(f)] Bottom area used in calculations only[310 CMR 15.252(2 i)] a Address / Sheet 5 of 7 N/A OK NO ID, E f Pressure Dosed Sysiem ? Provided pump and piping calculations as required [310 CMR 15.220(4)(r)] Pressure dosing'required on all systems>2000gpd or alternative systems under remedial approval [310 CMR 15.254(2) and I/A Remedial Use Approvals] If used in gravelless system make sure jet is directed as not to scour soil interface [Guidance Document] Inspections once per year(systems<2000 gpd) or quarterly (>2000 d) good to note on plan (310 CMR 15.254(2)(d)] Construction in fill Did the plan spedfy'that the fill shall meet the specification of 310 CMR 15 255(3)? Impervious barrier and/or retaining wall? [Guidance Document] ,/ Impervious'barrier installation must be supervised by designer[310 CMR 15.255(2)(b)] Retaining wall must be designed by Registered Professional Engineer [310 CMR 15.255(2)(a)] Side slope not exceed 3:1 ? [310 CMR 15.255(2)] Breakout requirements met? [310 CN4R 15.252(2) and Guidance Document], At least 51t. from impervious.barrier to edge of SAS (10 ft. recommended [3I0 CMR 15.255 (2 e)] s _ r Check DEP A royal lettersTfor credits and design condi"tions If used with pressure dosing do not allow pressure discharge to scour soil interface Was DEP Approval'Letter provided and/or have you / reviewed the letter for conditions? Is the technology being properly applied and does it meet all DEP Approval Conditions? (/ Is there a note on the plan regarding the requirement for perpetual maintenance agreement? Any alarms involved on separate circuits Did the applicant submit an operation and maintenance manual? Has applicant submitted a copy of a maintenance Are the variances listed on the plan?[310 CMR 15.220 (4)( ] RLS Stamp necessary on plan if a component is within five / feet of property line [310 CMR 15.412(4)] t/ New construction or increased flow proposed- [Refer to 310 CMR 15.414] v Address Sheet 6 of 7 N/A OK NO Is the system in a Designated Nitrogen Sensitive Area(Zone H for a public supply well)? [310 CMR 15.214, 310 CMR 15.215 and / 310 CMR 15.216 - also refer to Policy regarding upgrades of such existing systems] Is the system proposed on the same lot as served by private well ? [310 CMR 15.214(2)] Are the nitrogen loads proposed in compliance? [310 CMR 15.216(l)] Pumping to se tic tank ? [ 310 CMR 15.229] Shared System [310 CMR 15.290] I Address Sheet 7 of 7 CERTIFICATE OF ANALYSIS ~�`�� •• Page: 1 Barnstable County Health Laboratory rstr f{L�t: Report Pt-epared For: Report Dated: 9/17/2010 Skip Gibson Gibson Home Insspection Order No.: G1059889 298 Oakmont Road Yannouthport, MA 02675 Laboratory 1D#: 1059889-01 Description: Water-Drinking Water Sample#: Sampling Location: 145 Meadow Lane West Barnstable,MA Collected: 9/16/2010 Collected by: Skip Gibson Received: 9/16/2010 Routine ITEM RESULT UNITS RL MCL Method# Tested Nitrate as Nitrogen 0.10 mg/L 0.10 10 EPA 300.0 9/16/2010 Copper 0.16 mg/L 0.010 1.3 EPA 200.8 9/16/2010 Iron ND mg/L 0.25 0.3 EPA 200.8 9/16/2010 Sodium 19 mg/L 0.25 20 EPA 200.8 9/16/2010 Total Coliform Absent P/A 0 0 SM9223 9/16/2010 Conductance 84 umohs/cm 2.0 EPA 120.1 9/16/2010 pH 6.1 pH-units 0 SM 4500 H-B 9/16/2010 Water sample meets the recommended limits for drinking water of all the above tested parameters.-I Attached-please find the laboratory certified parameter list. Approved By: 142 (L irector) SEP23RECD ay ND=None Detected RL = Reporting Limit MCL=Maximum Contaminant Level Superior Court House, PO.Box 427, Barnstable, MA 02630 Ph: 508-375-6605 09/17/2010 FRI 9: 45 FAX 5083627103 Barnstable CTY HealthLab --- Barnstable Health 2001/001 t HAS': CERTIFICATE OF ANALYSIS Page: I Barnstable County Health Laboratory sstc s��% Report Prepared For: Report Dated- 9/17/2010 Skip Gibson Gibson Home Insspectiori Order No.: G1059889 i 298 Oakmont Road ----.._..--------Yannouthport, MA 02675 Laboratory ID#: 1059889-01 Description: Water-Drinking Water Sample h: Sampling Locatiow,145 Meadow Lane West Barnstable,MA ' Collected: 9/16,12010 Collected by: Skip Gibson Received: 9/16/2010 r Routine ITEM RESULT UNITS RL MCL Method# Tested Nitrate as Nitrogen 0.10 mg/L 0.10 10 EPA 300.0 9/162010 € mg/L 0.010 1.3 EPA 200.8 9/1612010 Copper 0.16 Iron ND mg/L 0.25 0.3 EPA 200.8 9/162010 Sodium 19 mg/L 0.25 20 EPA 200.8 9/162010 Total Coliform Absent P/A 0 0 SM9223 9/162010 Conductance 84 umobs/cm 2.0 EPA 120.1 9/162010 1 pH 6,1 pH-units 0 SM4500H-B 9/10010 Water sarnple meets the recommended 11mits for drinking water of all die above tested parameters.,j Attached please find the laboratory certified parameter list. Approved By: (L irector) I f k I 5 i i ND=None Detected RL = Reporting Limit MCL=Maximum Contaminant Level Superior Court House, PO.Box 427, Barnstable, MA 02630 Ph:508-375-6605 1 1 E i E i IET I\ Town of Barnstable01 `'r'',st we 1 ). Regulatory Services Department (3AR S'CABI '^ Q' Public health Division Via. 639. m j =ram 200 Main Street Hyannis MA 02601 200 Office: 508-862-464-4 Thomas F.Geiler,Director FAX: 508-790-63G4 Thomas A.McKean,CI-10 CERTIFIED MAIL# 70083230000251782701 6/24/2010 Constance Holt O 145 Meadow Circle West.Barnstable MA 02668 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 145 Meadow Lane, West Barnstable MA was last inspected on May 24, 2010, by Marl Polselli, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Failed" under the guidelines of\1995 TITLE 5 (310 CMR 15.00) due to the following: • Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool. You are ordered to repair or replace the septic system within Sixty (60) days from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future, enforcement action. PER ORDER OF THE BOA OF HEALTH Thona cKean R.S. Agent of the Board of Health Commonwealth of Massachusetts Title 5 Official Inspection Form ' o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments .� i�e �' �o r,✓ /V Property Address ( Ho v�tS �yG �l— Owner Owner's Name information is C,✓e s � r�/h A L Oa 66� .S �� /D required for ` State Zip Code Date of I specti every page. CitylTown 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: A. General Information When filling out forms on the computer,use 1. Inspector: only the tab key to move your cursor-do not use the return Name of Inspector key. �/V/0 Company Name � 'V /� a/flm I I m 10 /- Company Addr ,', 149 0.16 City/Town State 4fOd�o� Zip Code 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 1<5.340 of Title 5 (310 CMR 15.000). The system: ❑ Passes ❑ Conditionally Passes Fails Syj �a i ❑ Needs Further Evaluation by the Local Approving Authority n J /U Inspec is Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be 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. a Ois' "d/st P9e 1 of 17 tsins 09i08 Tit e5 Official inspection Form.:Subsurface 9 F� I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments �S Ae4 jot,/ z M + Property Address e Owner Owners Nam PS �n J 1 6�� / w cd-(.4 o'�` /0 information is ti required for State Zip Code Date of I spec on every page. Cityrrown B. Certification (cont.) Inspection Summary: Check A,B,C,D or E falways complete all of Section D A) System Passes: ❑ I have not found any rinformation CMRhich indicates 15 304exist Any fai urre crriterriiaure notcriteria described evaluated are in310CMR15.3030 indicated below. Comments: B) System Conditionally Passes: ❑ one or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. 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 exlltration 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): 15ins•09/08 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 / /Pe'- Col✓ Property Address / F Owner Owner's Name/ S J information is W e �— �iNS required for State Zip Code Date of Inspec on every page. City/Town B. Certification (cont.) 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 i5ins-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner Owner's Name � information is 6A q�- /� � required for State Zip Code Date of Inspection every page. City/Town B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: *'This system passes if the well water analysis, performed at a DEP certified laboratory, for 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: t 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 uuu 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 uuu than '/z day flow t5,ns•09/08 Title 5 of iciai Inspection form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form Not for Voluntary Assessments �7 Aeg cjo / Property Address Owner Owner's Name/ / information is W PS�-- /N �+6 l2 0�6 6t� _ required for State Zip Code Date o Inspection every page. Cityrrown B. Certification (cont.) Yes No zl-/Required pumping more than 4 times in the last year NOT due to clogged or ❑. ;,---�Any " structed pipe(s). Number of times pumped: portion of the SAS, cesspool or privy is below high ground water elevation. El Any portion of cesspool or privy is within 100 feet of a surface water supply or ❑ tributary to a surface water supply. ❑ L�' Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ Q�An portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP cert e ified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria'are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section D. Yes No t _ ❑ ET 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•09/08 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachus etts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form • Not for voluntary Assessments ' N Property Address /Vo/ / Owner Owner's Name /� II // �j_ O� 6 5�' .24� information is �eJ }' �"4 6/L —� required for State Zip Code Date of Inspection every page. Cityfrown C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes N (] P ping information was provided by the owner, occupant, or Board of Health ❑ Were any of the system components pumped out in the previous two weeks? Has the system received normal flows in the previous two week period? Have large volumes of water been introduced to the system recently or as part of this inspection? Were as built plans of the system obtained and examined? (If they were not available note as N/A) Was the facility or dwelling inspected for signs of sewage back up? Was the site inspected for signs of break out? Were all system components, excluding the SAS, located on site? 0/ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, / dimensions, depth of liquid, depth of sludge and depth of scum? ❑ Was the facility owner (and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: lam' 0 ting 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: c7Z Number of bedrooms (design): Number of bedrooms (actual): �o DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): I 15ins•09r08 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 �Lfs ,IV61a C/o PI/ Z_ Property Address Owner Owners Name i information is required for State Zip Code Date of Ins ection every page. City/Town D. System Information Description: 000 �X t Number of current residents: Does residence have a garbage grinder? ❑ Yes No Is sewage a system? [if yes separate inspection required] ❑ Yes No laundry on a separate 9 Laundry system stem inspected? ❑ Yes D No Seasonal use? ❑ Yes No Water meter readings, if available (last 2 years usage (gpd)): Detail: r �. Sump pump? ❑ es L�YNo VVLY/v'1 ' Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gailons 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•09r08 Title 5 official Inspection Form:subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner Owner's Name/ information is required for every page. City/Town State Zip Code Dat of Ins ection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ❑ No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of 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 1/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): 15ins•09r08 Title 5 Offioal Inspection Form:Subsurface Sewn ge Disposal system•Page 8 of 17 l_ Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments l 7� le" c/01 Property Address / Owner Owner's Name information is C 1 / rt104 required for ^`,P State Zip Code Date o Inspection every page. City/rown D. System Information (cont.) Approximate age of all comp5}ents, 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): 16. Depth below grade: feet Material of ccnstructi;40 ❑ cast iron PVC ❑ other (explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No sag Dimensions: ,,* Sludge depth: t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts U Title 5 Official Inspection Form Subsurface Sewage Disposal-System Form • Not for Voluntary Assessments � � � �e� coo c,✓ Z— Al' Property Address Owner Owners Name/ 1 L SG l //�f� D.1 6 information is Q,S T iN1 p � required for State Zip Code Date o Inspecti n every page. Cityrrown D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness / Cteeeuor Distance from top of scum to top ofeDistance from bottom of scum to bo or baffle How were dimensions determined? �•�IfI- Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): N/ 7`10 L, I -ee- ✓"errs► h — Grease Trap (locate on site plan): a 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: [fate t5.ns•09/09 True 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 jo j✓ Z'/ Property Address /� Owner Owners Name information is b le 66 required for State Zip Code Date of Inspection every page. Cityrrown 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 t5ms•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 I � L Com monwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form • Not for Voluntary Assessments Ale Z k9i - Property Address Owner Owners Name^/W J o�Y information is W required for State Zip Code Da a of Inspection every page. City/Town D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 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.): --------------------- 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.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•09/08 Title 5 Official Inspection Form:Suosurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments . Property Address Ao#— Owner Owners Name ✓h.S // ,fjl,/ �� a� information is required for f� every page. Cityrronm State Zip Code Dat of Inspection D. System Information (cont.) 6� TYpe: / leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: , Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth —top of liquid to inlet invert j Depth of solids layer Depth of scum layer j Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No 15ins-09108 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 Ale.. z� Property Address NO/� Owner Owner's Name,/ I J1��9 information is required for every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 15ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposat System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner Owners Name /N1/ / ,�,� information is 0�6 6t'j C�/�s�-- �G L � � .S required for State Zip Code Dath of Inspection every page. City/Town D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the age disposal system, inclu ' g ties to at least two permanent reference landmarks or benchmark . Locate all wells within 100 f et. Locate :Znd-s'ketch p bic water supply enters the building. Check one of boxes below: in the area below 1;,./e�� ❑ drawing attached separately L—; di I l a r J , / o A - 3 �� S�¢� i5ins•o9/o8 Title 5 Ofridal Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form • Not for Voluntary Assessments Property Address /�v / — Owner Owner's Name // ( information is required for /" State Zip Code Date Inspe lion every page. City/Town D. System Information (cont.) Site Exam: ❑ Check Slope l�❑ Surface water � Coy' ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ served 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: S : �L— /'0 L' C-j V,-./ Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-09108 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 � o Property Address D/� Owner Owners Name(, 6 6 a` information is / I �� required for "v e`f 'State Zip Code Date of Inspec on every page. City/Town E.. Report Completeness Checklist Inspection Summary: A, B, C, D, or E checked [�spection Summary D (System Failure Criteria Applicable to All Systems) completed System Information — Estimated depth to high groundwater etch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM t Mail To: NAME OF BUSINESS: QIV 71�h `/� � !'' Board of Health MAILING ADDRESS: 4S �� t� �.. //r�c� Gt//�� - Town of Barnstable TELEPHONE NUMBER: P.O. Box 534 Hyannis, MA 02601 CONTACT PERSON: v Does your firm store any of the toxic or hazardous materials listed below, either for sale or for your own use, in quantities totalling, at any time, more than 50 gallons liquid volume or 25 pounds dry weight? YES NO This form must be returned to the Board of Health regardless of a yes or no answer. Use the enclosed envelope for your convenience. If you answered YES above, please indicate if the materials are stored at a site other than your mailing address: ADDRESS: TELEPHONE: LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health has determined that the following products exhibit toxic or hazardous characteristics and must be registered y - "� -j' rqurd �' "� > Please put a check beside each product that you store: Antifreeze (for gasoline or coolant systems) Drain cleaners Automatic transmission fluid Toilet cleaners Engine and radiator flushes Cesspool cleaners Hydraulic fluid (including brake fluid) Disinfectants Motor oils/waste oils Road Salt (Halite) Gasoline, Jet fuel AI Refrigerants Diesel fuel, kerosene, #2 heating oil Pesticides (insecticides, herbicides, Other petroleum products: grease, lubricants rodenticides) Degreasers for engines and metal Photochemicals (fixers and developers) Degreasers for driveways & garages Printing ink Battery acid (electrolyte) Wood preservatives (creosote) Rustproofers Swimming pool chlorine Car wash detergents Lye or caustic soda Car waxes and polishes Jewelry cleaners Asphalt & roofing tar Leather dyes Paints, varnishes, stains, dyes Fertilizers (if stored outdoors) Paint & lacquer thinners PCB's (.� Paint & varnish removers, deglossers Other chlorinated hydrocarbons, it Paint brush cleaners (inc. carbon tetrachloride) Floor & furniture strippers Any other products with "Poison" labels Metal polishes (including chloroform, formaldehyde, Laundry soil & stain removers hydrochloric acid, other acids) (including bleach) Other products not listed which you feel may Spot removers & cleaning fluids be toxic or hazardous (please list): (dry cleaners) Other cleaning solvents Bug and tar removers Household cleansers, oven cleaners White Copy-Health Department/ Canary Copy-Business J TOWN OF BARNSTABLE fOMPLIANCE: CLASS: 1.Marine,Gas Stations,Repair BOARD OF HEALTH satisfactory 2.Printers O 3.Auto Body Shops ,� " �� unsatisfactory- 4.Manufacturers COMPANYt 71/ �!.�,4� / 9Qf� (see"Orders") s.Fuel SStores pl ers ADDRESS 5"9A 19 at.. o 2P Class: 7.Miscellaneous QUANTITIES AND STORAGE (IN=indoors;OUT=outdoors) MAJOR MATE SUnderground IN OUT IN ;OUT IN OUT #&gallons Age Test Fuels: Gasoline,Jet Fuel (A) Diesel, Kerosene, #2 (B) Heavy Oils: waste motor oil (C) new motor oil (C) transmission/hydraulic Synthetic Organics: degreasers Miscellaneous: t - DISPOSAL/RECLAMATION REMARKS: 1. Sanitary Sewage 2. Water Supply O Town Sewer Public O On-site OPrivate 3. Indoor Floor Drains YES NO O Holding tank: MDC O Catch basin/Dry well O On-site system 4. Outdoor Surface drains:YES NO ORDERS: O Holding tank:MDC O Catch basin/Dry well O On-site system 5.Waste Transporter Name of Hauler Destination Waste Product p YES NO 2. Pit �- Person (s) Interviewed Inspe for Date I � TOP OC FOUNDATION mmHmm SOIL TEST 20 FT. MINIMUM FROM CELLAR OR CRAWL SPACE DATE OF SOIL TEST DUNE=6 2010 P 12970 ELEV. _ ��_ 10 FT. MINIMUM 10 FT. MINIMUM FROM SLAB „ SOIL TEST DONE BY SWEETSER ENGINEERING CLEAN SAND WITNESSED BY Q_STANTQN (ASSUMED) CONCRETE INSPECTION PORT COVERS 4" SCHEDULE 40 PVC PIPE LOAM A,ND SEED OBSERVATION HOLE 1 ELEV.=_92.3_ MIN. PITCH 1/8" PER FT. 2" LAYER OF 1/8 TO 1/2" PERCOLATION RATE < -2-- MIN./INCH AT _63__ INCHES TWASHED STONE T F,,A °�2, MAX, OR ^ILTER FABRIC VENT DEPTH HORIZ TEXTURE COLOR MOTT. OTHER 4" A IR N PIPE A 4 r CAST 0 N. 13,Of •� NOT REQUIRED 0-10" A LOAMY-SANG- _ _ 10YR5/3 NO ROOTS (OR EQUAL) MINIMUM -- PITCH 1/4" PER FT. z 10-27" 8p - LOAMY SAND ---- 10YR7 6 ROOTS t TEE 27-120" C FINE SAND 2.5Y8/2 FLOW LINE `,�•� °' NO WATER ENCOUNTERED AT 120_ ELEV. _ _ 82.3 ELEV. 97. _ 10" 4 -TMIN. i _ _ _[77 OBSERVATION HOLE 2 ELEV.=_ 92.4- ELEV. " LEVEL coon = = c 10" ELEV. _ _88.47- I= --- ELEV. � _ ADD 'GA 6 SUMP - - BAFFLE ELEV. _ _89•70 ELEV. _ _89_53_ DEPTH HORIZ TEXTURE COLOR MOTT. OTHER DISTRIBUTION 0-10" Ap LOAMY SAND 10YR5/3 NO ROOTS ELEV. = 4 HIGH CAPACITY INFILTRATORS WITH LIQUID OUTLET 60X _$$�Q_ STONE IN AN 10-26" B LOAMY SAND 10YR7/6 ROOTS aDEPTH TEE FEET 14 INCHES (EXISTING) TO BE WATER TESTED " 6.17 -_ . _ -.-- 11 X 36 X 10 TRENCH F0 MATION 26-120" C FINE SAND 2.5Y8 2 5 FEET 19 INCHES IF MORE THAN ONE OUTLET NO WATER ENCOUNTERED AT ?20" ELEV. _ _ 82.4 _ 6 FEET 24 INCHES 1000 GALLON SOIL ABSORPTIOi WELL N/A 7 FEET 29 INCHES (TO BE PLACED ON FIRM BASE) ZONE 8 FEET 34 INCHES SEPTIC TANK 3/4" TO 1 1/2" CLEAN S DEX DOUBLE WASHED STONE SYSTEM (SAS) INDEXADJUST a FREE OF FINES & SILT SEWAGE DISPOSAL SYSTEM PROFILE OBSERVED UWATER SGS RTABLE ( WA/R f BL) ELEV _ ------ SEWAGE NOT TO SCALE BOTTOM OF TEST;HOLE ELEV. = DESIGN CALCULATIONS NOTES: NUMBER OF BEDROOMS 2 ACTUAL DESIGN FOR 3 1. ALL WORKMANSHIP AND MATERIALS SHALL CONFORM TO D.E.P. GARBAGE DISPOSAL UNIT NO TITLE 5 AND THE TOWN'S RULES AND REGULATIONS FOR TOTAL ESTIMATED FLOW THE SUBSURFACE DISPOSAL OF SEWAGE. 110 GAL R./bAY X 3 8R.) _� 4_ GAL./DAY 2. ALL COVERS TO SANITARY UNITS SHALL BE BROUGHT TO WITHIN 6" OF FINISHED GRADE. REQUIRED SEPTIC TANK CAFACITy, � 5r,�a _ GAL. 3. ALL COMPONEWS-OF THE SANITARY SYSTEM SHALL BE CAPABLE OF ACTUAL SIZE OIF SEPTIC ANu ( ' _1 GAL.SO'L CLASSEFICkTION 1-- WI TT HSTANDNt H-t10 LOADING UNLESS THEY ARE UNDER OR WITHIN 10 FT. OF DRIVES OR PARKING AREAS. H-20 LOADING SHALL BE DESIGN PERCOLATION RATE < '3__ MIN./IN. USED UNDER OR WITHIN 10 FT. OF DRIVES OR PARKING AREAS. \ 0 EFFLUENT LOADING RATE Qj_f_ GAL./DAY/S.F. 4 ANY MASONARY UNITS USED TO BRING COVERS TO GRADE SHALL LEACHING W OING+A47X2X10/12) 474.33 SO. FT. BE MORTARED IN PLACE. \ OJ LEAvr'NG CAPACITY (AREA X RATEj _ 5tDQ GAL./DAY `J NO DETERMINATION HAS BEEN MADE AS TO COMPLIANCE WITH I 33 X 0.74 DEEDED OR ZONING REGULATIONS. OWNER / APPLICANT IS TO 474. h00 ON OBTAIN SUCH DETERMINATION FROM APPROPRIATE AUTHORITY. RED':?`T 33 N'^: SHED G CAPACITY _d � GAL./DAY 6. UTILITIES SHOWN ARE APPROXIMATE ONLY, EXCAVATION CONTRACTOR 26 909 90 IS TO CALL "DIG-SAFE" AT 1-888-344-7233 AT LEAST 72 HOURS 90•7 PRIOR TO COMMENCING WORK ON SITE. 7. CONTRACTOR IS TO VERIFY GRADES AND ELEVATIONS AS WELL AS 1.4 SITE CONDITIONS PRIOR TO COMMENCING WORK ON SITE. ANY VARIATION i IS TO BE BROUGHT TO THE ATTENTION OF THE DESIGN ENGINEER IMMEDIATELY. C 8 PARCEL IS IN FLOOD ?_ONE -------- 4'W ri .^.t":*t C?Ai 1��FSc�.c LOAP .__134 _ AS FARCE 21 6/1 '' �� STE-ST 1 ,ti 10. EXISTING LEACH PIT IS TO BE PUMPED AND BACKFILLED OR REMOVED. 11. THE INSTALLER IS To GIVE THE ENGINEER A MINIMUM OF 48 HOURS y r #~w �' ► ~' t (2 WORKING DAYS) NOTICE FOR THE FINAL INSPECTION (NUMBER BELOW). SOIL* \M TEST 2 \ N. D. BOX9 .5 \ �- GRA VEL or n r 'per / Q " 1000 GALLON 0,, - J 9 .6 T TANK F ,. ,. _TS.870,f, S.r \\ SEP IC N \ t - : 3 �\ Y4, APPROVED: BOARD OF HEALTH •f9 ° 5\ r 96.7 / �J - S1h / / t ,s� 9 x 94.4 t,�( Y , 0 DATE AGENT �I SHED 9 8.6 \ 99.0 .E ,z 97.6 / WEST BARNSTABr1E, MASS. PROPOSED SEPTIC DESIGN CP EXISTING WELLING 9&6 / r 97 \ 3 BE OOMS 99.1 3 FOR 99. � 1 // , CONSTANCE & DOUGLAS HOLT LOCUS v / 99:4 LOC. MEADOW Lh) 3145 , LVT 99.// 9.5 .- / //� Ile 6q oo�i , WEST BARSTABLE, MASS. �o 3.5 Oi p CO ��P o_ 99.5 � � �jNrY r ��rr��r ��tt//��I►��rtyy7��rr�/�+rr 99.5 /, // � GJ� HIGH ST �+ 1aLa~7� �il'rVL�G.UlLlLYtT { 203 SETUCKET ROAD air-ASPHAL r �g GAP EXIST 4 508- P. 0. BOX 713 99.5 // �// 385-6900 SOUTH DENNIS, MASS. 02660 LEGEND: EXISTING SPOT ELEVATION OOXO � 99.4 % // �lg \C, o�TF` FDUNE SCALE " ' EXISTING CONTOUR ----00---- �99.7 1 6, 201 0 1 = 20 FINAL SPOT ELEVATION 00.0 FINAL CONTOUR 98.8 99V. JOB N0. SIL TEST UOTILITY POLE LOCATION 99.3 9� 7 Z 3 Z,D/D 6952-00 TOWN WATER -W - W i CATCH BASIN G;®� �(98 /96. REV.CLEAN ouT o0 7.7 �97.5LOCATION MAP 7 7 z ?� SHEET / OF 1 CESSPOOL C.P. Q / C.• S8 PROD 6952-00\dw 6952-SAS.OWG 02010 SWEETSER ENGINEERING •