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HomeMy WebLinkAbout0192 MEADOW LANE - Health 192 MEADOW LANE,W. BARNSTABLE A= 158 005 �E1 a p �l i Commonwealth of Massachusetts D "D05'DD� ,W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments a G.'V M 192 Meadow Ln Main House Property Address Cirenda Wildlife Land Trust k.s.4 Owner Owner's Name information is West- s� required for every Barnstable W Ma 02630 1/30/18 page. City/Town State Zip Code Date of Inspection ,e ^fw7 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 filling out forms A. General Information on the computer, use only the tab 1. Inspector: key to move your cursor-do not Michael DiBuono use the return Name of Inspector key. DiBuono Sewer and Drain r� Company Name 35 Content Ln Company Address Cotuit MA 02635 Cityrrown State Zip Code 508-364-9587 SI 13522 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: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation b ocal Ap roving Authority 2/1/18 nspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form - s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ��M ,••'y< 192 Meadow Ln Main House Property Address Orenda Wildlife Land Trust Owner Owner's Name information is required for every Barnstable Ma 02630 1/30/18 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: ® 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: System contains a 1500 gallon septic tank. As well as a concrete distribution box and 9 High cap Infultrators shared with the cottage house for a total of a 5 bedroom system 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 ears old*or the septic tank whether metal p y p ( eta 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 192 Meadow Ln Main House Property Address Orenda Wildlife Land Trust Owner Owner's Name information is required for every Barnstable Ma 02630 1/30/18 page. Cityrrown 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 Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 192 Meadow Ln Main House Property Address Orenda Wildlife Land Trust Owner Owners Name information is required for every Barnstable Ma 02630 1/30/18 page. Citylrown State Zip Code Date of Inspection 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 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 ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloa ded 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-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 192 Meadow Ln Malin House Property Address Orenda Wildlife Land Trust Owner Owner's Name information is required for every Barnstable Ma 02630 1/30/18 page. Cityrrown State Zip Code Date of Inspection B. Certification Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 MR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 I Commonwealth of Massachusetts W Title 5 Official Inspection Form �_ r Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 192 Meadow Ln Main House Property Address Orenda Wildlife Land Trust Owner Owner's Name information is required for every Barnstable Ma 02630 1/30/18 page. Citylrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 5 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 550 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts 4 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 192 Meadow Ln Main House Property Address Orenda Wildlife Land Trust Owner Owner's Name information is required for every Barnstable Ma 02630 1/30/18 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: Vacant Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonaluse? ® Yes ❑ No Water meter readings, if available last 2 ears usage d NA 9 ( Y 9 (gP ))� Detail: Sump pump? ❑ Yes ❑ No Last date of occupancy: 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts 4 Title 5 Official Inspection Form - � Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 192 Meadow Ln Main House Property Address Orenda Wildlife Land Trust Owner Owner's Name information equir for is every Barnstable required for eve Ma 02630 1/30/18 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Unknown Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 192 Meadow Ln Main House Property Address Orenda Wildlife Land Trust Owner Owner's Name information is required for every Barnstable Ma 02630 1/30/18 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 7/22/99 Were sewage odors detected when arriving at the site? ❑ Yes ❑ No Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ® cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): Depth below grade: 1.5 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) 1500 If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 192 Meadow Ln Main House Property Address Orenda Wildlife Land Trust Owner Owner's Name information is required for every Barnstable Ma 02630 1/30/18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 24" Scum thickness 3" Distance from top of scum to top of outlet tee or baffle 42" Distance from bottom of scum to bottom of outlet tee or baffle " Sludge stick How were dimensions determined? Tape Measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 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 M 192 Meadow Ln Main House Property Address Orenda Wildlife Land Trust Owner Owner's Name information is required for every Barnstable Ma 02630 1/30/18 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 M 192 Meadow Ln Main House Property Address Orenda Wildlife Land Trust Owner Owner's Name information is Barnstable for every Ma 02630 1/30/18 Cit !Town page. Y State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Level and at normal level 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.): Camera inspection to Distribution box showed no signs of back up or failure 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-3/13 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 192 Meadow Ln Main House Property Address Orenda Wildlife Land Trust Owner Owner's Name information is required for every Barnstable Ma 02630 1/30/18 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ® leaching galleries number: 9 High cap Infultrators ❑ 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.): Camera inspection to Distribution box showed no signs of back up or failure 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 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 192 Meadow Ln Main House Property Address Orenda Wildlife Land Trust Owner Owner's Name information isequired or every Barnstable Ma 02630 1/30/18 page. Cityrrown 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.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments GM ,.•�''v 192 Meadow Ln Main House Property Address Orenda Wildlife Land Trust Owner Owner's Name information is required for every Barnstable Ma 02630 1/30/18 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form A' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 192 Meadow Ln Main House Property Address Orenda Wildlife Land Trust Owner Owner's Name information isequired or every very Barnstable Ma 02630 1/30/18 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 156" 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: Nov 9 1998 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Test hole data on plan 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 OWN OF BARNSTkBLE 9Z del GYRO ��LOCATION SEWAGE # VILLAGE ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. 771 SEPTIC TANK CAPACITY LEACHING FACILITY: (size) NO. OF BEDROOMS_ BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility (If any wetlands exist within 300 feet of leaching facility) Feet Furnished by 13 o4 13 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM ,•'" 192 Meadow Ln Main House Property Address Orenda Wildlife Land Trust Owner Owner's Name required for is every Barnstable required for eve Ma 02630 1/30/18 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ❑ Inspection Summary: A, B, C, D, or E checked ❑ Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ❑ System Information— Estimated depth to high groundwater ❑ Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;Y 192 Meadow Ln Cottage Property Address Orenda Wildlife Land Trust Owner Owner's Name Cl information is bl t arnsae I, required for every B 4l.�at Ma 02630 1/30/18 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: key to move your cursor-do not Michael DiBuono use the return Name of Inspector key. DiBuono Sewer and Drain r� Company Name 35 Content Ln Company Address Cotuit MA 02635 City/Town State Zip Code 508-364-9587 SI 13522 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: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evalualtiqlaby the oa roving Authority 2/1/18 spector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system 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. LTtd us t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 192 Meadow Ln Cottage Property Address Orenda Wildlife Land Trust Owner Owner's Name information is required for every Barnstable Ma 02630 1/30/18 page. Citylrown 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: ® 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: System contains a 1500 gallon septic tank. As well as a concrete distribution box and 9 High cap Infultrators shared with the main house for a total of a 5 bedroom system 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 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 192 Meadow Ln Cottage Property Address Orenda Wildlife Land Trust Owner Owner's Name information is required for every Barnstable Ma 02630 1/30/18 page. Citylrown 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 Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 192 Meadow Ln Cottage Property Address Orenda Wildlife Land Trust Owner Owner's Name information is required for every Barnstable Ma 02630 1/30/18 page. Citylrown State Zip Code Date of Inspection 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 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 ❑ ® 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 192 Meadow Ln Cottage Property Address Orenda Wildlife Land Trust Owner Owner's Name information is required for every Barnstable Ma 02630 1/30/18 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts 4 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 192 Meadow Ln Cottage Property Address Orenda Wildlife Land Trust Owner Owner's Name information is required for every Barnstable Ma 02630 1/30/18 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 ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 5 Number of bedrooms (actual): 1 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 550 t5ins•3/13 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 GSM ,•'' 192 Meadow Ln Cottage Property Address Orenda Wildlife Land Trust Owner Owner's Name information is required for every Barnstable Ma 02630 1/30/18 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: Vacant Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonal use? ® Yes ❑ No Water meter readings, if available last 2 ears usage d NA 9 ( Y 9 (gP ))� Detail: Sump pump? ❑ Yes ❑ No Last date of occupancy: 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 — - i Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M "t 192 Meadow Ln Cottage Property Address Orenda Wildlife Land Trust Owner Owner's Name information is required for every Barnstable Ma 02630 1/30/18 page. City/Town 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: Unknown Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M , 192 Meadow Ln Cottage Property Address Orenda Wildlife Land Trust Owner Owner's Name information is required for every Barnstable Ma 02630 1/30/18 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 7/22/99 Were sewage odors detected when arriving at the site? ❑ Yes ❑ No Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ® cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 1.5feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) 1500 If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 192 Meadow Ln Cottage Property Address Orenda Wildlife Land Trust Owner Owner's Name information is required for every Barnstable Ma 02630 1/30/18 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 24" Scum thickness 3" Distance from top of scum to top of outlet tee or baffle 42" Distance from bottom of scum to bottom of outlet tee or baffle " Sludge stick How were dimensions determined? Tape Measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 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 192 Meadow Ln Cottage Property Address Orenda Wildlife Land Trust Owner Owner's Name information is required for every Barnstable Ma 02630 1/30/18 page. Cityrrown 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 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 192 Meadow Ln Cottage Property Address Orenda Wildlife Land Trust Owner Owner's Name information is required for every Barnstable Ma 02630 1/30/18 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Level and at normal level 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.): Camera inspection to Distribution box showed no signs of back up or failure 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: l5ins•3/13 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 ,M 192 Meadow Ln Cottage 9 Property Address Orenda Wildlife Land Trust Owner Owner's Name information is required for every Barnstable Ma 02630 1/30/18 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ® leaching galleries number: 9 High cap Infultrators ❑ 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.): Camera inspection to Distribution box showed no signs of back up or failure Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM ,e'y 192 Meadow Ln Cottage Property Address Orenda Wildlife Land Trust Owner Owner's Name information is required for every Barnstable Ma 02630 1/30/18 page. Citylrown 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.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 192 Meadow Ln Cottage Property Address Orenda Wildlife Land Trust Owner Owner's Name information is Barnstable Ma 02630 1/30/18 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately l5ins•3/13 Title 5 Official 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 192 Meadow Ln Cottage Property Address Orenda Wildlife Land Trust Owner Owner's Name information is Barnstable Ma 02630 1/30/18 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 156" 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: Nov 9 1998 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Test hole data on plan 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 OWN OF BARNSTABLE LOCATION ` � SEWAGE # VILLAGE W' �Q��-3f� ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. ����D� i �O/�,,5�` 771r1'9 SEPTIC TANK CAPACITY bl):�XAV% 162�22 r�`LTat`,C'J I�a LEACHING FACILITY: ( ) C1cL l f �� (size) NO. OF BEDROOMS BUILDER OR OWNER j PERMITDATE: ? '—Z Z '�� COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet j Edge of Wetland and Leaching Facility (If any wetlands exist within 300 feet of leaching facility) Feet Furnished by _ I i i I i i i I i i i 1 0 ' ro8 t-/ t6d moo' c -3 L� ' c. -1 +�' ® C Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 192 Meadow Ln Cottage Property Address Orenda Wildlife Land Trust Owner Owners Name information is required for every Barnstable Ma 02630 1/30/18 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ❑ Inspection Summary: A, B, C, D, or E checked ❑ Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ❑ System Information— Estimated depth to high groundwater ❑ Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 LOCATION 17z�f OF BARNSTABLE VILLAGE CitJi �Qi' SEWAGE # INSTALLER'S NAME PHONE NO ASSESSOR'S MAp&LOT SEPTIC TANK CAPACTTy ®I"�®Le C���� 771 LEACHING FAC 1L No- OF BEDROOMS (size) BUILDER OR OWNER PERMI TDATE: Separation Distance BetweenCOMPL�CE the: DATE: � Maximum Adjusted Groundwater Table to the Bottom of Leaching I Private Water Su htng Facility � Supply Well and Leaching FacilityFeet on site or within 200 feet of leaching ) many wells e Edge of Wetland and facility) exist within 3 Leaching Facility(Han 1 00 feet of leachingY wetlands exist Feet Furnished by facility) � Feet I e I i I r MOWN OF BARNSTABLE b� L0CltT10N di? #&4 4 61.1) Iywe— SEWAGE # VILLAGE �!/ 't i 482V 2"A ASSESSOR'S MAP & LOTf67- INSTALLER'S NAME&PHONE NO. 4, SEPTIC TANK CAPACITY w �, LEACHING FACILITY: (type) 9-6 4' n (size) f NO. OF BEDROOMS BUILDER OR-OWNER 1 s" PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility -Feet Private Water Supply Welland Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and aching Facility(If any wetlands exist within 300 fee f acW acility) Feet Furnished G" r LIZ l back oe W. 5 n - r OWN OF BARNSTABLE LOCATION 19z � ` SEWAGE # VILLAGE W 4�reAf9�/1e ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. CD���L� 771 - SEPTIC TANK CAPACITY rl k , 16i 22 C'.--4 LEACHING FACILM: i �` Cc9�� (size) 1 NO. OF BEDROOMS BUILDER OR OWNER PER MITDATE: 7 7 �� `COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by `2. 'E too N. i " Al Fee O p� THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS RpPlication for,Mi5pogar *p5tem Construction Permit Application for a Permit to Construct(J)Repair( )Upgrade( )Abandon( ) CVrComplete System ❑Individual Components Location Address or Lot No. 101 A me*vsw 144. Owner's Name,Address and Tel.No. Y Assessor's Map/Parcel �56�c�1J� �f}• 4�o Fo7 Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 1W151 s Type of Building: Dwelling No.of Bedrooms Lot Size (• sq.ft. Garbage Grinder Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow. 15156 gallons per day. Calculated daily flow 55 gallons. Plan. Date //, I—9 9�, Number of sheets Revision Date Title !!!5DTp f 5(rg% ' Size of Septic Tank I500 (-A+G Type of S.A.S. Description of Soil Nature of Repairs 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 until a Certifi- cate of Compliance has been i by this d of ea h. 3 Signed Date Application Approved by Date Application Disapproved for t e fol wing reasons i L .i Permit No. Date Issued Fee` cc) f T&COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLES MASSACHUSETTS k A AM%a�tion�for ig o�aI *potent �tComaruction Per tri t-- Application for a Permit to Construct(J)Rpair( ')Upgrade( )Abandon( ) CKComplete System O Individual Components Location Address or Lot No. /1'a M t,400 ) L q- Owner's Name,Address and Tel.No. Assessor's Map/Parcel i f G� 5- . 1W,4 - N-0V7 Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. DOejd CiAQFL />1wR5ravls �ccc5 �/N�- �2l-R3q9 C($1 /�iprnr /4p�Mounf,vN� - b��ZS Type of Building: Dwelling No.of Bedrooms Lot Size t)Q(• sq.ft. Garbage Grinder 0V) / Other Type of Building No. of Persons Showers( ) cafeteria( ) Other Fixtures \\ Design Flows gallons per day. Calculated daily flow SS gallons. Plan Date 17 Cb Number of sheets Revision Date Title '!5/7TC 4 Size of Septic\Tank Type of S.A.S. \Description of Soil Nature of Repairs or Alterations(Answer when applicable) a Date last inspected: Agreement: -r The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title_5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been i by this Board of ea h. Signed Date Application Approved by Date — Application Disapproved for Me folhAing reasons Permit No. - cl L/ .�! Date Issued ————--——————is—————————————————————————— THE'COMMONWEALTH OF MASSACHUSETTS ' BARNSTABLE, MASSACHUSETTS r Certificate of Compliance s THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed Repaired graded ' g P Y ( ) P ( )UPg- (` ) Abandoned( )by 44 at has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No, dated Installer Designer M' The issuance of this permit shall not b construed as a guarantee that th�e it unction as desig z'd' Date / Inspect�ir�```"� � _' --------------------------------------- No. / - 3 Fee S) THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS. li000l *p.5tent Construction Verntit ' Permission is hereby granted to Construct(Repair( )Upgrade( )Abandon( ) _ /' System located at 1 C) a 17i1_� .�1 .r Lai LkAt(i4444 JL and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must-bee completed within three years of the date of thi rmit. Date: 7 �'2 2'/ Approved by _ _ Page 2 of 3 R.I. Analytical Laboratories, Inc. CERTIFICATE OF ANALYSIS Envirotech Laboratories, Inc. Date Received: 4/30/99 Approved by: Work Order# 9904-03791 R.I. aly cal Sample#: 001 SAMPLE DESCRIPTION: 994556 BARNSTABLE 4/28/99 @0115 SAMPLE DET. ANALYZED PARAIVILETER RESULTS LDiIIT CUTS METHOD DATE/TIME ANALYST Volatile Organic Compounds Bromodichloromethane <0.5 0.5 ug/1 EPA 524.2 5/12/99 10:03 JAH Bromoform <0.5 0.5 ug/t EPA 524.2 5/12/99 10:03 JAH Dibromochloromethane <0.5 0.5 ug/l EPA 524.2 5/12/99 10:03 JAH Chloroform <0.5 0.5 ug/1 EPA 524.2 5/12/99 10:03 JAH 1,2-Dibromoethane(EDB) <0.5 0.5 ug/I EPA 524.2 5/12/99 10:03 JAH Benzene <0.5 0.5 ug/I EPA 524.2 5/12/99 10:03 JAH Carbon Tetrachloride <0.5 0.5 ug/I EPA 524.2 5/12/99 10:03 JAH 1,2-Dichloroethene <0.5 0.5 ug/I EPA 524.2 5/12/99 10:03 JAH Trichloroethene <0.5 0.5 ug/l EPA 524.2 5/12/99 10:03 JAH 1,4-Dichlorobenzene <0.5 0.5 ug/l EPA 524.2 5/12/99 10:03 JAH 1,1-Dichloroethane <0.5 0.5 ug/l EPA 524.2 5/12/99 10:03 JAH 1,1,1-Trichloroethane <0.5 0.5 ug/1 EPA 524.2 5/12/99 10:03 JAH Vinyl Chloride <0.5 0.5 ug/I EPA 524.2 5/12/99 10:03 JAH Bromobenzene <0.5 0.5 ug/I EPA 524.2 5/12/99 10:03 JAH Bromomethane <10 10 ug/I EPA 524.2 5/12/99 10:03 JAH Chlorobenzene <0.5 0.5 ug/1 EPA 524.2 5/12/99 10:03 JAH Chloroethane <5 5 ug/l EPA 524.2 5/12/99 10:03 JAH Chloromethane <5 5 ug/1 EPA 524.2 5/12/99 10:03 JAH 2-Chlorotoluene <0.5 0.5 ug/l EPA 524.2 5/12/99 10:03 JAH 4-Chlorotoluene <0.5 0.5 0 SPA 524.2 5/12/99 10:03 J.. Dibromomethane <2 2 ug/1 EPA 524.2 5/12/99 10:03 JAH 1,3-Dichlorobenzene <0.5 0.5 ug/I EPA 524.2 5/12/99 10:03 JAH 1,2-Dichlorobenzene <0.5 0.5 ug/l EPA 524.2 5/12/99 10:03 JAH trans-1,2-Dichloroethene <0.5 0.5 ug/1 EPA 524.2 5/12/99 10:03 JAH cis-1,2-Dichloroethene <0.5 0.5 ug/1 EPA 524.2 5/12/99 10:03 JAH Methylene Chloride <0.5 0.5 ug/I EPA 524.2 5/12/99 10:03 JAH 13-Dichloroethene <0.5 0.5 ug/I EPA 524.2 5/12/99 10:03 JAH 1,1-Dichloropropene <0.5 0.5 ug/I EPA 524.2 5/12/99 10:03 JAH 1,2-Dichloropropane <0.5 0.5 ug/I EPA 524.2 5/12/99 10:03 JAH 1,3-Dichloropropane <0.5 0.5 ug/1 EPA 524.2 5/12/99 10:03 JAH 1.3-Dichloropropene <0.5 0.5 ug/1 EPA 524.2 5/12/99 10:03 JAH 2,2-Dichloropropane <0.5 0.5 ug/l EPA 524.2 5/12/99 10:03 JAH Ethylbenzene <0.5 0.5 ug/1 EPA 524.2 5/12/99 10:03 JAH Styrene <0.5 0.5 ug/I EPA 524.2 5/12/99 10:03 JAH 1,1,2-Trichloroethene <0.5 0.5 ug/l EPA 524.2 5/12/99 10:03 JAH 1,1,1,2-Tetrachloroethane <0.5 0.5 ug/I EPA 524.2 5/12/99 10:03 JAH 1,1,2,2-Tetrachloroethane <0.5 0.5 ug/1 EPA 524.2 5/12/99 10:03 JAH Tetrachloroethene <0.5 0.5 ug/1 EPA 524.2 5/12/99 10:03 JAH R.I. Analytical Specialists in Environmental Services CERTIFICATE OF ANALYS IS Envirotech Laboratories, Inc. Date Received: 4/30/99 Attn: Mr. Ron Saari Date Reported: 5/13/99 449 Rte. 130 P.0. #: Sandwich, MA 02563 Work Order #: 9904-03791 DESCRIPTION: MAIN POST & BEAM (ONE WATER SAMPLE) Subject sample(s) has/have been analyzed b our � y y o laboratory with the attached results. Reference: All parameters were analyzed by U.S. EPA approved methodologies. The specific methodologies are listed in the methods column of the Certificate Of Analysis. If yo4havey ue ions garding this work, or if we may be of further assistance, please contact us. Appr Jame ' h 4ichael J. Vice resi it Quality Coa(rol Coordinator enc: C ain f Custody 41 Illinois Avenue,Warwick, RI 02888 950 Boylston Street, Unit 102, Newton Highlands, MA 02461 Tel: (401) 737-8500 Fax: (401) 738-1970 Tel: (61 7) 965-5133 Fax: (617) 965-5624 ENVIROTECHLABORATORIES,INC. MA CERT.NO.:M-MA 063 449 Rte. 130 Sandwich, MA 02563 508(888-6460) 1-800 339-6460 FAX(908)888-6446 CLIENT: Main Post& Beam LOCATION: Lot 192 ADDRESS: Go Pilgrim Well Meadow Lane W. Barnstable, MA COLLECTED BY. Rich M./Pilgrim Well SAMPLE DATE: 4-28-99 SAMPLE TIME. 1:15PM WATER SAMPLE TYPE: New Well DATE RECEIVED: 4-29-99 LAB I.D. #. 994556 WELL SPECS.: N/A RESULTS OF ANALYSIS: Parameters Units Recommended Results Method Date Analyzed Limits Coliform bacteria /100ml 0 0 9222 B 4/29/99 pH pH units 6.5-8.5 6.45 4500 H+ 4/29/99 Conductance um'hos/cm 500 220 120.1 4/29/99 Nitrate-N/Nitrite-N mg/L 10.0 0.71 4500-NO3 E 4/29/99 Sodium mg/L 28.0 27.5 200.7 5/3/99 Iron mg/L 0.3 0.03 200.7 5/3/99 Manganese mg/L 0.05 0.013 200.7 5/3/99 Potassium mg/L 20.0 2.4 200.7 5/3/99 Calcium mg/L N/A 8.1 200.7 5/3/99 Magnesium mg/L N/A 4.0 200.7 5/3/99 Hardness(as CaCO3) mg/L 500 36.7 200.7 5/3/99 Alkalinity mg/L 200 20.2 2320 B 5/3/99 Sulfate mg/L 250 10.9 375.4 4/30/99 Chloride mg/L 250 50.1 4500-CI L 4/30/99 Color APC units 15.0 < 5.0 2120 B 4/30/99 Turbidity NTU 5.0 0.52 2130 B 4/30/99 Volatile Organics ug/L See Report ND EPA 524.2 5/12/99 ND = None Detected. COMMENTS: pH is below recommended limit and may have corrosive characteristics. WATER MEETS EPA STANDARDS AND IS SUITABLE FOR DRINKING PURPOSES FOR PARAMETERS TESTED. Z�i � - Date Ro Id J. S ari Laboratory it for <=less than >=greater than TNTC=too numerous to count 6 L f � OII --:�. II i , 1 I i I .i I Department of Environmental Management/Division of Water Resources 9 . WELL COMPLETION REPORT k A WELL LOCATION 1t GEOGRAPHIC DESCRIPTION Address C Q T 1912 N S E W of Pam.do a-1 �/7. (feet) (circle) City/Town �!,,�/.,�//6".1 Pa,;kr ,h3n� Well owner rV sd ! IPx-c,�n (road) Address / . I N S tD W of (mi.in tenths) circle) Board of Health permit obtained: yes no ❑ intersect. w/ 4S►`� (road) WELL USE WELL DATA Domestic Public❑ Industrial ❑ Total well depth 00 ft. Monitoring❑ Other Depth to bedrock .t/ . VA ft. Water-bearing rock/unconsolidated material: Method drilled AlrA .Per_ Description Date drilled 9 Water-bearing zones: CASING t �, 1) From To Type 2) From To Length 2,s ft. Dia(I.D.) in. 3) From To Length into bedrock IV- 4- ft. Gravel pack well: dia. Protective well seal: dia. Screen: Grout '❑ Other -S�r� Slot#---L-6 length__T_from-!Sto STATIC WATER LEVEL (all wells) Static water level below land surface ft. Date— WELL TEST(production wells) Drawdown ft. after pumping hr._0 min. at g p m How measured IrAg!44 Recovery_ ft. after_ hr.___t___1_0nin. LOG of FORMATIONS COMMENTS Materials From To g 10, U U Driller av' Firm AuS i'n.c (!/��� d In Da Address e?.0 P"�.rr��v]� �✓/ City/Town /'" Supervising Driller Reg.# y Signature of supervising registered well driller Please print firmly BOARD OF HEALTH COPY Th oeS . \ D AT E : 3/20/98 AA APR - 9 PE'RTY ADDRESS: 192 Kb dow Lane Pn rO"OF 9�� Cs?� HE41N�;STAB(f �� - West Barnstable, Mass. 02668 On the above date, I Inspected the saptic system at the above ac�:"ee = Tnls system consists of the following: 1 . 2-6 ' x6 ' block cesspools. oase-o on my InPc,-actlon, I certify the following conditions: 2 . This is not a title five septic system. 3 . The two cesspools are dry.Has all new Sch. 40 4" PVC pipe and fittings from the house to the #1 cesspools t to the #2 cesspool . 4 . The sewage system is in proper working order , at the present. . 1 5 . #1 Cesspool is within 75 ' of the 11 J� / Name : _J _P . Macomber Jr____ ____ . Company:�_ P_Hacomber— &— Son _Inc , _ _Cencervi1Le `Ha99__02632 �none : c a , 5.,3338_------ THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRA,,i T r )OSEPH P, MACOMBER & SON, INC. T4nk►-C.upooI►-L4 achtleIdi Pump*d L Iniull►d Town Suer Connoctlont P.O. Box 60 ' Centerville, MA 02632.0066 775-3338 77!-6 12 } I COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET, BOSTON, MA 02108 617.292•5500 w'ILL1.4S1 F WELD TRL'D) C Govcmor Sc:r ARGEO PAUL CELLUCCI D.-\vID B STR Lt.Govcmor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Cornmiss PART A CERTIFICATION Property Address:192 Meadow Lane West Barnstabl%ddress of Owner: Date of Inspection: 3/2 0/9 8 (If different) Name of Inspector:JciSe pb P Mac-tuber Jr. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15,000) Company Name: ,T.P.Macomber & Son Inc. Mailing Address: Rox 6A r..PntEL1T111em Mass 09632 Telephone Number: n o -7-r 5 333 o CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is uue, accura and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper iunci,on anc maintenance of on-site sewage disposal systems. The system: _L/Passes Conditionally Passes Needs Further Evaluation By the Local Approving Authority _ Fails / Inspector's Signature: i Date: GCS The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing tn,s inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system ow.,er shall subm the repon to the appropriate regional office of the Department of Environmental Protection. The original should be sent to :he ss gem ow, and copies sent to the buyer, if applicable, and the approving authority. INSPECTION SUMMARY: Check A; B, C, or D: A) SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CmR 15.30 Any failure criteria not evaluated are indicated below. COMMENTS: B) SYSTEM CONDITIONALLY PASSES: VO One or more system components as described in the "Conditional Pass" section need to be replaced or repaired, -the systerr., uo completion of the replacement or repair, as approved by the Board of Health, will pass. Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If "not determined', expla n wny not �e The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection. the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfilt.a(ion, or ta; failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conform,ng septic :anr as approved by the Board of Health. (revised 04/25/97) D&ge 1 of 10 DEP on the Worid Wide Web: http:/twww.mapnet state ma us/oep Printed on Recycled Paper r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property address: 192 Meadow Lane West Barnstable,Mass. Owner: Charles Birdsey Date of Inspection: 3/20/98 B) SYSTEM CONDITIONALLY PASSES (continued) /VO&C Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstruced pipets) or due to a broken, settled or uneven distribution box. The system will pass inspection if (with approval of :ne Board of Health). Describe observations: broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced A V The system required pumping more than four times a year due to broken or obstructed pipe(s). The system wil: pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed C1 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 pro(e-0 the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A tiLANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM 15 FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: •,26 The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the pre rice of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance ;7% � (approximation not valid). 3) OTHER t � i (revisod 04/35/27) P&y• 2 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 192 Meadow Lane West Barnstable,Mass. Owner: Charles Birdsey Date of Inspection:3/2 0/9 8 D) SYSTEM FAILS: You must indicate er;-er 'Yes" or "No" as to each of the following: I have determined that the system violates one or more of the following failure criteria as defined in 310 CmR 15.303 Tne basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes NO Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. —VO/i t�- Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspoo! I _ Liquid depth in cesspool is less than 6" below inven or available volume is less than 1/2 day flow. Required pumping more than a times in the last year NOT due to clogged or obstructed pipe($). Number of times pumped Q—. Any ponion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water suppiti Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no .,acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. I E) LARGE SYSTEM FAILS: You must indicate either "Yes" or "No" as to,.each of the following: '/ The following criteria apply to large systems in addition to the criteria above: yd The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No /& the system is within 400 feet of a surface drinking water supply A the system is within 100 feet of a tributary to a surface drinking water supply Ii� the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area • IWPA) or a mapper Zone ii of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information (rwir.od 04/25/97) P&g• ) of 10 I� SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 192 Meadow Lane West Barnstable,Mass . Owner: Charles Birdsey Date of Inspection:3/2 0/9 8 Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes No i Pumping information was provided by the owner, occupant, or Board of Health. None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. large volumes of water have not been introduced into the system recently or as part of this inspection. As built plans have been obtained and examined. Note if they are not available with N/A. _ The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow. _ The site was inspected for signs of breakout. _ All system components, eluding the Soil Absorption System, have been located on the site. �dti)E The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. —The size and location of the Soil Absorption System on the site has been determined based on: The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub-Surface Disposal System. Existing information. Ex. Plan at B.O.H. _ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) (15.302(3)(b)). (r*v1sed 04/25/97) P&9. 4 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 192 Meadow Lane West Barnstable,Mass . Owner: Charles Birdsey Date of Inspection:3/20/98 FLOW CONDITIONS RESIDENTIAL: Design flow:'j3'Q g.p.d./bedroom for S.A.S. Number of bedrooms: Number of current residents:Q Garbage grinder (yes or no):_,(2Q Laundry connected to sy t!m (yes or no):,4h Seasonal use (yes or no): s �I . .•Lac?�' �Jv.�� Water meter readings, if available (last two (2) year usage (gpd): Lya? � 14" �7 itic _�_ Sump Pump (yes or no):� /CS'� /� 7-44d 11,49r l.�s /�/r�s r -Pfts�'����' doge,172e4d, Av- IV A�t 47-4 f- 6-74 Last date of occupancy:` COMMERCIAUINDUSTRIAL: Type of establishment: Design flow:_d.),4 allons/day Grease trap present: (yes or no).(/n Industrial Waste Holding Tank present: (yes or no) Non-sanitary waste discharged to the Title 5 system: (yes or no)-444 Water meter readings, if available: 1/0 ,44 Last date of occupancy: OTHER: (Describe) da Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of i r ation: System pumped as part of inspection: (yes or no)A!p If yes, volume pumped: gallons Reason for pumping: TYPE OF SYSTEM ,6 Septic tank/distribution box/soil absorption system Single cesspool j Overflow cesspool _Q Privy 414 Shared system (yes or no) (if yes, attach previous inspection records, if any) ,V I/A Technology etc. Copy of up to date contract? Other A,lQi APPROXIMATE AGE of all components, date installed (if known) and source of information: Sewage odors detected when arriving at the site: (yes or no)_/W (revised 04/25/97) Page 5 of 10 BARNSTABLE COUNTY HEALTH AND ENVIRONMENTAL DEPARTMENT SUPERIOR COURT HOUSE BARNSTABLE, MASSACHUSETTS 02630 'yA 89 PHONE:362-25 i? 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 one inch air space. Do not fill bottle to the top. Be careful not to touch the inside of the bottle or cap with the faucet, your hands, or any- thing else. 5. Fill out the reverse side. The laboratory requires accurate and complete informa- tion. 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 4:00. They must be deliv- ered 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 handles through the town water departments. 10.Completion of tests and results takes 7-10 days. Results will be sent in the mail. NOTICE: WATER FROM THE SAME SOURCE CAN PRODUCE CONTRARY RESULTS IF TESTED AT DIFFERENT TIMES AND/OR DIFFERENT LOCATIONS. THE COUNTY OF BARNSTABLE SHALL NOT BE LIABLE FOR DAMAGES RESULTING FROM THE RELIANCE ON RESULTS OF WATER TESTS ACCU- RATELY PERFORMED. PLEASE COMPLETE REVERSE SIDE OF FORM PLEASE READ INSTRUCTIONS ON REVERSE SIDE BEFORE COMPLETING THIS FORM 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) Crown or City) (State) (Zip) (Town) Telephone: Year House was Built: Bottle Identification Number: Well Depth Feet (Taken from Bottle) Reason for testing (Check one): ❑ suspect a problem ❑ required by DEgE ❑ 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. Distance of supply from possible contarnination sources (check all that apply): septic tank'/ cesspool - � feet ❑ farm feet ❑ salted highway feet 0 buried fuel tank feet ❑ land fill feet ❑ other feet Treatment used: ❑ none ❑ water softener ❑ filter SIGNATURE OF SAMPLE COLLECTOR ❑ Well Driller ❑ Owner ❑ Realtor ❑ Tenant ❑ Other ------------------------------------------------------------------------------------- - FOR LAB USE ONLY - --Total oliform / 100 ml pH Conductivity (micromhos / cm) Iron (ppm) Nitrate- Nitrogen (ppm) Sodium (ppm) Copper (ppm) • (Jl SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM \ PART C SYSTEM INFORMATION (continued) Property Address: 192 Meadow Lane West Barnstable,Mass . Owner: Charles Birdsey Date of Inspection:3/20/98 BUILDING SEWER: (Locate on site plan) Depth below grade: Material of co struction: cast iron 40 PVC _ other (explain) Distance from, ivate water supply well or suction line an ;OC.�. , Diameter ''S��` Comments: (condition of joints, ventin evidence of leakage, etc.) SEPTIC TANK:�pVc_ (locate on site plan) Depth below grader Material of consuuaion:Af�/concrete•,y 4metaW�FiberglassN�Polyethylene i other(explain) A111 If tank is metal, list age d&,4 Is age confirmed by Certificate of Compliance t�(Yes/No) Dimensions: Sludge depth:_ Distance from top of sludge to bonom of outlet tee or baffle:_ Scum thickness:_,�� Distance from top of scum to top of outlet tee or baffle: Z1W Distance from bosom of scum to bottom of outlet tee or baffle: How dimensions were determined: A//# Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) (�Tr7'A41Ar Y4 wT r GREASE TRAP:, V-- (locate on site plan) Depth below grader Material of construct ion;,V4concrete4 netaW0Fiberglass4/APolyethylen&9/ other(explain) 41A Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: -411' Distance from bottom of sc,�m to bottom of outlet tee or baffle: '* Date of last pumping: / Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet inven, structural integrity, evidence of leakage, etc.) r e 2' op (rrvtsed 04/25/91) P&y• 6 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 192 Meadow Lane West Barnstable Owner: Charles Birdsey Date of Inspection: 3/2 0/9 8 TIGHT OR HOLDING TANK:AW(Tank must be pumped prrur to, or at time, of inspection) (locate on site plan) Depth below grade: Nit Material of con struciion:,tJ1concrete,edmetat,( Fiberglass. /Pol yet hyleneAAother(explain) —AA - Dimensions: Capacity: J gallons Design flo. gallons/day Alarm level Alarm in working order J.�eYes;,VA Nu Date of previous pumping. _Z4_ Comments (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: docate on site plan) Deptn c: I-cv-d level above outlet rnven:�� Commer-:s (note ii level avid distribution is'equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) S AUT�1'� PUMP CHAMBER:z4Q /e, (locate on site plan) Pumps r working order (Yes or No) /710 Alarms n ,.orking order (Yes or No) Alr�- Comments (note condition of pump chamber, condition of pumps and appunenances, etc.) 1pj� r I (r.vi•.e 0�/1S/97) ➢.g• 7 of 10 V SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 192 Meadow Lane West Barnstable,Mass. Owner: Charles Birdsey Date of Inspection:3/2 0/9 8 SOIL ABSORPTION SYSTEM (SAS): )& 4 �l✓ p � (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: leaching pits, number: O leaching chambers, number: leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Alternative system: A Name of Technology: Comments: (note condition of soil, si ns of hydraulic failure, level of ponding, condition of vegetatio etc.) O �. CESSPOOLS: (locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater: inflow (cesspool must be pumped as part of inspection) -� 1V�Z: d s©l/i71L�• Comments: Inote condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY:.. D ,>% (locate on site plan) Materials of construction: /?/� Dimensions: �J Depth of solids: A)4 Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) (revimed 04/25/97) Page 8 of 10 F SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION ORM PART C SYSTEM INFORMATION (continued) Properly Address: 192 Meadow Lane West Barnstable,Mass . Owner: Charles Birdsey Date of Inspection: 3/2 0/9 8 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) 2�f' . � / ' bock o4 No'j e, i ( i / 0 ` q a ri E-0. 0l.o I-v 10, • lr•vif•C O4/25/97) Pay• 9 of 10 -ESSORS LOT 5 `:• "SSORS MAP 156 SMITH CREEK ! II CHARLES RUSTIC! ��, 2308/346 280,700t5J 6.44•PC- LOT 2 l8XM7+SF. 40-AC,(WETLAND) \ 43.7421SF. WOPAC. (UPLAND) \ 256r&9tiSf. 520 AC- (TOTAL) CB./C • FND. %9 CB./D.H. FND. •� \� �_� L-472r 56932' I / PAVED Q` LOT \. ROAD 75,706*SF. 173*AG(WETLAND) h / 239.003tSF. &49tA- (UPLAND) 4 / FN� .�ti 314709'SF. 722-AC.(TOTAL) 1 / _ / JCBID.H 1 h TOWN OF B.,I FND. .\� �" GUY WIRE y JY: GARDEN v, / ISTY. ^ %.GIANT .'Aa J DWELLINGS / JY' GUY WIRE. y W/F DWELLING FND. �� �fl •y', Saen ;� o Pool �F,�i �. �� / \\ END. ROUND C.B. )SHED P & R 0, G p y / FND. y� STAIRS FENCE D. DRIVE SHED \ • �y� j �G i /~ l` NOTE: C>- �F '(sue �._-COY IIVEGE Gpw- FND. r Sib r?,I61Y_\ LEGEI (CALC.TIE) N.TS. N.T.S. I I I I I r ,1V SUBSURFACE SEWAGE DISP;. t SYSTEM INSPECTION FORM r. C SYSTEM INFOI: :ION (continued) Property Address: 192 Meadow Lane West Barnstable,Mass, Owner: Charles Birdsey Date of Inspection:3/2 0/9 8 Depth to Groundwater !01 Feet Please indicate all the methods used to determine High Groundwater Etc' a:ion: Obtained from Design Plans on record r bservation of Site (Abutting property, bservation hole, basenv-r-1$imp etc.) Determine it from local conditions Check with local Board of health Check FEMA Maps Check pumping records Check local excavators, installers Use USGS Data Describe in your own words how you established the High Ground+ner Elevation. Must be completed) Used Water Contours Map. Gahrety & MIller Model 12/16/94 (rev1o.d 04/25/17) P.S. 10.1 10 1 �•nrnr+.—n+rs•—..-+'t— '.r:mr•nmrvT.n rerrrrm:-.'s+•+e+an•:�rrsrmn ns•+�it'+a'r.rs+r+e' � .. I TOWN OF Barnstable BOARD OF HEALTH SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D .- CERTIFICATION `. �•••r.• �T••.-•. .-T. r.-..:T-nr.r-n-rtrsirlT ms'+rT.+T•+:�—t-t*'lvs+7arrtvr'�T1iA.Z�rRT+Crt'IncTI�Cr7 Rmn-*srrtrrrr*n-r+rr.r.:—.r r.- r-•� .-.. -TYPL OR PRINT CLEARLY- PROPERTY I NSPECT'ED STREET ADDRESS 192 Meadow Lane West Barnstable ASSESSORS MAP , BLOCK AND PARCEL # IFT �� `3"l e OWNER' s NAME Charles Birdsey PART D - CERTIFICATION I NAME OF INSPECTOR Joseph P.Macomber Jr. COMPANY NAME J.P.Macomber & Sern' Inc. COMPANY ADDRESS Box 66 Centerville,Mass . 02632 Street Town or City Stat. LIP COMPANY TELEPHONE ( 508 ) 775 - 3338 FAX ( 508 ) 790 - 1578 fi CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system nt this address and that the information reported is true , accurate , and complete as of the time of -inspection . The inspection was performed and any recommendations regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems . Check one V S s teui PASSED y The inspection which I have conducted has not found any information which indicates that the system fails to adequately protect public health or the environment as defined in 310 CMR 15 . 303 . Any failttr•e criteria not evaluated are as stated in the FAILURE CRITERIA section of this form. System FAILED* The inspection which I have con acted has found that the system fails to Protect the public health and the environment in accordance with Title .5 , 310 CMR 15 . 303 , and as specifically noted on PART C - FAILURE CRITERIA of this inspection form . le , Inspector Signature Date One copy of this certification must be provided to the OWNER, the BUYER ( Where applicable ) and the I30ARD OF HEAL7'il. * If the inspection FAILED, the owner or""operator shall upgrade ' the system within one year of the date of the inspection , unless allowed or required otherwise as provided in 3.10 CF1R 16 . 305 . partd . doc f <11 Ul Z7 !7 ti - S byV 3i 7l THE CONZ.MONWEA.LTH OF MA.SSA.CHUSETTS DEPA.TM.0 i NT OF ENVZRONNTENTA.L PROTECTION BE IT KNOWN THAT Joseph P. Macomber, Jr. Has satisfied the Department's qualificatiq ns as required and is hereby authorized to use the title CERT < < D TITLES SYSTEM INSPECTOR as provided in 310 CMR 15 .340 and Section 13 of Chapter 21A of the General Laws . Issued by Tllc Department of Environment.-il Protection . nc ting [)ttcctvt u( the O�✓t<<c :t U( Wild ['<111%11101) Conuol J u --------- BOARD OF HEALTH TOWN OF BARNSTABLE Zipplicat ion ArVeil Con!5tructionpermit Application is hereby made for a permit to Construct ( ), Alter ( ), or Repair ( )an individual Well at: Location — Address Assessors Map and Parcel Address /�Owner Installer — Driller Address Type of Building Dwelling--- - ------------------------------------------- Other - Type of Building---------------------------- No. of Persons----------------------- ----------- r� Type of Well --- — ----— - Capacity---— - - --——--— --- Purpose of Well---- "'� ��Z.------------------ Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation — The undersigned further agrees not to place the well in operation until a Certificate .of Compliance has been issued by the Board of Health. �� Signed —---- --- — — _— -L�,I�'_'---9- date Application Approved - 1< - — ----- _ — Ir date Application Disapproved for the following reasons:--------------------------------------------- ------- - - ------ ----------------------------------------------- --------- ------------ date Permit No.—J � __ Issued—'4010 �I-- ---- date _....-...-..--------------------------- -------------------------_---------------- -------------`---- ' - -- -- --- -------------------------------- -------------- BOARD OF HEALTH TOWN OF BARNSTABLE Certificate Of Compliance THIS IS TO CEERTIFY, That the Individua Well Constructed ( ), Alt ed ( or Repaired ( ) by---- -�-- 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. ated—"- _ -THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE--- -- Inspector-------------- ------------------ BOARD,OF HEALTH _. TOWN . OF BARNSTABLE Applicatcon-*rMeft �Congtrurt[on ermit Application is hereby made for a permit to Construct ( ), Alter ( ), or Repair (. )an individual Well at: Location %Address Map and Parcel G; - �9a /� 1 �jAAsssessors el Owner 4L- J2J1� /S�1 M--Ale—��--lU — �FRl►S6�G —Address�f. — -- — Installer —"Driller Address -— — Type of Building I ` Dwelling `'j(k -------------------- ----------- Other - Type of Building--= -=---- ------ No. of Persons--=-------------------------_______ Type of Well YP ---------------- - - Capacity-- ------------------------------ I Purpose of Well - i I Agreement: The undersigned agrees to install the`aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation - The undersigned further agrees not to place the well in operation_until a Certificate of Compliance has been issued by the Board of Health. G Signed - - ------- -- _- =°I -pL — — date „ Application Approved .. �✓� ------ — �_� '�� date 1 Application Disapproved for the following reasons: — -- _ - — ---- ---- — date Permit No. J'r' --- Issued-- - ` - ! ----— date :�F3:! •�aF�e.i•R�4-�:!:".!.r�,:.�ieiew!:e,YNiilae.l:l2lr.rw!!�yi:�•.;i�.i'M�;�:ses�,frc!afa4+1•a:s!reTdcraEaF�yRi7Ns�P!.�:la�i�x�yese?7�?w*f!%7tiAs^;h7Hp�s•Kvse�aaassagas+�!Yhsea;:eaei�!:m:.u:!s!:!, BOARD BOA OF HEALTH , i TOWN OF BARNSTABLE Certificate Of Compriance THIS IS TO CERTIFY, That the Individual Well Constru ted ( ), Alt - d ( ) or Repaired( ) by installer has been installed in accordance with the-provisions of the Town of,Barnstable Board �off Health ealth��Pri�rivate Well Protection Regulation as described in the application for Well Construction Permit No. `—�L: -Mated — THE ISSUANCE-OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL,FUNCTION.SATISFACTORY.. DATE---- - Inspector-- -- - 7:•:lFr.t':!:tia�aa•Mae:t:s•:Ncea+csaeaeYgsTi9 rye:it/Kpa+p}kYK.l4RbH�s�!esp7te!!as�ta9ir•+z!!•;galaeaisa��]►r!{ess!p'eis.►+Kli!'!ierrSslie:"wee':!iM:?r1�_s4i�is3'!ilisi!ww_+c"wr�!rw!aeai=+ BOARD: OF,HEALTH`. TOWN OF BARNSTABLEMelt Co'n5tructionA3ermit No. - Fee Permission is hereby granted'r- �` j° ✓ ��''` r--L!s �� _— f to Construct ( L Alter ), or Re air (I .an Individual Wel% y Street ' i as shown on the a plication for a Well Construction Permit i No.---- ' Dated - - -- - Z ,._ Board of Health , DATE I Department of Health,Safety+and Environmental Services Date lrj Public Health Division dr 367 Main Street,llyennis MA 02601 I I Time Fee Pd. �> — waver G� ,�,aA.n�- t°y Date Scheduled w or Sewage Disposal ant a r Soil Suitability Assessor f Witnessed By: Performed By: dCA'C10N �c G�N�itAL INf+ORMATION Uk%oa" L pwner'sNeme Je2re3 Location Address 9� �'`ems'"' k`� Address Engineer's Name Arrv� Assessorb Mep/Pe<�I: �� s Telephone A '�6 Z 45y REPAIR N NEW CONSTRUCTION — O Surface Stones Slopes( ) Land Use Drinking Water Well Open Water Body Possible Wet Area �_ Q Distances from: pe Other Property Line —n Dralnage Way • dimensions of l04 exact locations of test holes dt pero log,locals wetlands in proximity 10 hots) SKETCH:(street nsore .1 i E' I y° �2 '� t �r�� elf• . ..< . �,• ; �`'Q•St� w 1 \� fi 1 Depth to Bedrock 3� +I parent materiel(geologic) p Depth to Groundwater: Standing'+/ater In Hole: 2. weeping Eton+Ph Fes Estimated Seasonal High Groundwater T� TI0 FORS NASONA���GHVATtlt L ' .t.,;... DCTERM[NA y&tR� in. Method Uscd: in. Depth to 1011 mottles• /t' R' Depth Observed standing In obs.hole: In. Groundwater Adjuslmenprou dwater Level Depth to weeping from side orobs.hole: Ad),rector j Index Wel M__..... •Reading Dale: Index Well level _ ,e t pEACOLA`I"IOI 5 t add : . Time et 9" Observetio •' ifole N !L // 'hnw at 6" Depth or Pere - ', Th!"(y' _0 Y✓►^ Start Pre-soak Time®. -i---� � End Pre-soak CAh ��, C P1 Rat Min.Anch �� /N � � Site Failed: Additional Testing Needed(Y" e Site Suitability Assessment: Site Passed�— Observation Hole Data To Be Completed on Back------) original: Public Health Division Copy: Applicant 1LOLr LOG bole#�— Snil Ullrcr I)I''l'.11 0II51�'�ZVAI lUrl'fexlure SnilColnt Molllind (Slruclure.Slone„f!y��de _ Snil (MunselQ i),plh from S011110111.011 (tISUA) Lao Surface(I nJ 0-9 L� ScWa IM cwI /,0o� 1Zt� C 0rL V /rjU C.li ItVSA'C�C�N �IOILC S.:o.l i u re.5 r. Rt'ut6eres. r Soil Color Motilln{ (Stnrcl soil Ilorizon (USDA) (Munsell) t _ I)cpIh rrom D� �d • V Surface(in.) [7 yl ,,gyp i4r- r! d� Q !Z G �wd �o y/l �00 No S�r"cf v P lZ'�� •• IImIE#.r--t��er VIOL L C� Soil Bouldcres. uhrr dljSLitVA'rldry Son Color Mouling (5lrudure,Sim+es, Soil Texture (Mansell) uer tlr from Soil i lorizon (USDA) � Surface(In.) 1zOLC L00 Ilnle# �IUN Sa Ulhct ()BS goA Soil Color soil Stnleture.Stoner,potrldctes. Soll Texture (Munsell) Mottling l)cplh from Soil Ilorlaon (USDA) Surface(In.) I �fl�yttn�r.B��R' No Above 500 year Good boundary • Within Soo year boundary, No Yes h ._... .. within 100 year flood boundary No, Yes Does at(cast four feet of naturally occurring p ervi ous materiel exist in all aretis observed throughout the area proposed for the soil absorption system? �- If not,whet Is the depth of naturally occurring pervious material? callQn ' ' l roved by the °�`1 (dote)I have passed the soil evaluator examination opp a td by ant wEt I certify that on `'`` yis was erfottned bA i f' mental Protect---�!t and that the eA , _ 17. :f f?nviron - - _ _:r__.! � aR ESA TOWN OF BARNSTABLE UNDERGROUND FUEL AND CHEMICAL STORAGE SYSTEMS / r � NAME ADDRESS !�a �=��� � � VILLAGE s4 0/1 LOCATION OF TANKS: CAPACITY: TYPE OF FUEL AGE: TYPE: OR CHEMICAL ze led '/J ;2 o®® ,�s�/,e% i 97,. Sl/z-:c L (Give same information for any additional tanks on reverse side of card) DATE OF PURCHASE OF EACH: 1. ` ? 7Z2. 3. 4. DATE OF FIRE DEPARTMENT PERMIT: 7 TESTING CERTIFICATION SUBMITTED: PASSED DID NOT PASS �1N r w v, �oF7HETo TOWN OF BARNSTABLE OFFICE OF COPY i BAR—STABLE, • MAE& .BOARD OF HEALTH °ems i63 O MAY 6� 367 MAIN STREET 'E w� HYANNIS, MASS. 02601 February 17, 1981 THIRD REQUEST' Mr. James J. 11allameyer Hallameyer' s 13xpress, Inc. 192 Meadow Labe West Barnstable, Ma. I Re: Your underground fuel storage tanks located at R7 T'»tar_H ze Road Hyannis Dear Sir: On March 11 , and September 30, 1980, you were sent a copy of the Board of Health Regulation for Underground Fuel Storage and a card to fill out and return listing information concerning your underground tanks. I You have not teturned the card nor acknowledged our letter. i Town records indicate that you have received' a permit to store fuel underground. Please be advised that if you do not - ' return the enclosed card within five (5) days, steps will be taken to. revoke your permit. Appropriate action will then be taken to have your tanks neutralized or removed. You are also keminded that any tank fifteen years of age or ' older must be tested by the Kent-Moore Pressure Test. An empty tank ma,�> be tested by a 5PSI Air Pressure Test. This testing must lie done immediately. The enclosed v-ard must be filled out and returned immediately. Very truly Mirs, _2* i f_mtz Kelly ir of P;lkX Health JMK/mm encl. 1 - i Y _ I •� •v f• � q�� +'. � � s ,.. t tit _ } � � i� ,r � �r "� E/ {' -�'•:' _ + ^' „ -'� _ �1�`�.�Ja�es J�`..Ma1.�atn�tyer � ;� • � �; �., 4 .� ""- y ;, ;F Av Haam®yer s < Xpress, Ine 192 Meadow.Lane Y - ` t f ,s West 'B rnstable- ,.Ma, � 4 ., '�'y..c`,.�•j ' ♦ ,. a •?w r Z • ra.�` a 3- a »`r t �' _�'• 4 �' r r�P ; „�, -- -'� ,. ' � / • •+sue � I;- "3' :., «g -,+ _ 87 tex�pra se' Road Hyann sja .• a r a i T -%- � -r R.i.,,.. x ?.- ::i Y•i ,�,:,a _. - - *?` ;atl ....'-�/,, � C 'sr- 'r,..r 1 R.} r•'. / � y '4 F �' s„ a ; fi .alp. �" `.. +"" � ';°�„ k,rR > 'i � •- .l �3.• �`:�: tt 3"5'' ,'ate .ri 4. "� � y,., i a".•� �$' '� •`, e ' < � s ' � _ �. �t ti w ��$ - si. _T ->.,a♦ :ty; ti, ,, �.`., .f,... Y*,. �.r -..a p., "" Y - ..J t 1 , ' 'S',+}-" sr c's. '�'f• f" ��. rrebrr +-.- f t- i of s'a. F ?+�: ,r. "•�`''.' - a• � '"'� { / �/ ate �' 1`j x'�;. .'! 8"I'-• �/ � -r� t e h L J � �..���S - �:a� *, 'Kl t �{w.a ye -. * � .. +t * to ! a..."« s. ✓` {•y..-."•d ;._ t ' c 4 I; rf �.yA a_.,.,r r +z..� � 's :a� ,. V t -` � ,. -t .,w rS. ••v .t _,. .� ! - .-7 .r�+. - h s<r' `F' - .. + •mow - - �" •,s' '„a •ae` � ,.`k��: Y - "q t .A � a �*•.a � erg'wr � - .;° .. # , NAP�F�; CA'Toll C/o Hallameyer's Express,fnc. HALLAM�;Yr;R, James J. 87 E.ntercorise Rd. '1 :Z� ileaOow Lame Hyannis 11. -Barnstable, "!ass. 026.66 BOOK PAGE, - W.TE GW:�TED AMOUNT STORED 77/?39 9ept-pa er 30, 1�7Q PATE PATD 1973 - March a APR. , A, 8 1974 FEB 22 19€30 MAP `' WS OR 1 'l 19l n MAR 1 ' 1.97 Ji PROP. HOUSE ,- SEPTIU PROFILE T.O.F. AT EL. 18.50 TEST HOLE LOGS LEGEND , ACCESS COVER TO WITHIN 6" OF FIN. GRADE (NOT TO SCALE) 100.0 PROPOSED SPOT ELEVATION SEPTIC DESIGN: (GARBAGE DISPOSER IS NOT ALLOWED ) ACCESS COVER (WATERTIGHT) TO 5 M 110 GPD = 550 GPD 17.0' MINIMUM ,75' OF COVER V WITHIN 6" OF FIN. GRADE ENGINEER: A.H, OJALA, PE DESIGN FLOW. __ BEDROOMS ( ) E OVER PRECAST 2% SLOPE REQUIRED OVER SYSTEM 17•0 100x0 EXISTING SPOT ELEVATION USE A 550 GPD DESIGN FLOW WITNESS:_ J. DUNNING - \:15.5� OUS RUN PIPE LEVEL 2" DOUBLE WASHED PEASTONE DATE; 10/20/98 100 PROPOSED CONTOUR SEPTIC TANK: 550 GPD (2 ) = 1100 FOR FIRST 2 I PROPOSED 1500 / 3' MAX. PERC. RATE _ �: < 2 MIN/INCH USE A 1�00 GALLON SEPTIC TANK GALLON SEPTIC I` r 100 EXISTING CONTOUR LEACHING: AA REQUIRED = FLOW 0.75 TANK (H_ 10 ) 14G 91 14.0' CLASS I SOILS P# / 15.16 13.5�1 734 SQ. FT. = 550 / 0.75 _;.: .. TREE BAFFLE 13.76' �� o g HIGH CAPACITY t (56.25 + 4 + 1) x (3 + 4 + 4 + 1) = 735 SF ( 2 % SLOPE) 6" CRUSHED STONE OR MECHANICAL 1 4' ® SIDES COMPACTION. (15.221 [2]) so 0.91' INFILTRATORS o ELEV, ELEV. TOTAL: 735 S.F. 551 GPD DEPTH of FLOW = 4 1 $ 0 112.36' Q Q ( % SLOPE) p,r 20.29' p" 18.84' TEE SIZES: p 3 4 TO 1 1 2 DOUBLE WASHED STONE ^' P� USE 9 HIGH CAPACITY INFILTRA�"ORS WITH 4' OF. / � INLET DEPTH = 1O' Ap A STONE AT SIDES AND 2' AT ENDS (NONE UNDER) � r P M" OUTLET DEPTH = 14.r LS LS - 5.12' 8 10 YR 3 4 10YR 4/4 LOCATION MAP- SCALE 1"r> / 12" LEACHING - _ - FOUNDATION- 17' SEPTIC TANK 115' - D' BOX 32' Bw FACILITY gw LS FS ASSESSORS MAP 158 PARCEL 5-�4 BOARD OF HEALTH ZONING DISTRICT: RF 34 10YR 6/8 17.46 30" 10YR 5/8 YARD SETBACKS: rr r 16.34' MA FRONT -= 30' APPROVED DATE EXIST. COTTAGE ADJ. WATER (�1 7.24' T.O.F. AT EL. 23.37' C C SIDE 15' _ REAR 15' 21 .0' _ FS PLAN REF. MINIMUM .75' OF COVER OVER PRECAST FS 41 WELL: AND C ZONE:_•A W 252 2.5Y 7 6 2.5Y 5 3 FLOOD(HOUSE RESIDES LIN 1FLOODZON C y K�rK�00oe 19.5' / / E ) PROPOSED 1500 ADJ.: 1.4' GALLON SEPTIC 19.0' 19.25' TANK (H- 10 ) GAs 156" obs. water 5.84' BAFFLE 2.5% SLOPE) �6" CRUSHED STONE OR MECHANICAL COMPACTION. (15.221 [2]) 120" !0.29' 168" 4,84' AUGER HOLE RESULTS I(UNWITNESSED, PERFORMED 4/21/98)�/ S.F. NOTES: , AUGER HOLE 3 - 12" Bw1 FINE SAND 2.5Y 5/4 NGVD (4/21/98) 12" - ,33" Bw2 FINE SAND 2.5Y 6/6 1 . DATUM IS NOT AVAILABLE 16``- �` ,\ 10' 33" - 60" Cl FINE SAND 2.5Y 6/6 2. MUNICIPAL WATER IS \. �F 3. MINIMUM PIPE PITCH TO BE 1/8" PER FOOT. 60" - 122" C2 FINE SAND 2.5Y 6/4 4. DESIGN LOADING FOR ALL PRECAST UNITS TO BE AASHO H-•10 \`\ WATER ENCOUNTERED Air 113" (EL. 7.14') 5. PIPE JOINTS TO BE MADE WATERTIGHT. TH2 ADUSTMENT 0.1' � 6. CONSTRUCTION DETAILS TO BE IN ACCORDANCE WITH MASS. /�a \ ENVIRONMENTAL CODE TITLE V. r �O�' WELL: SDw 252 7, THIS PLAN IS FOR PROPOSED WORK ONLY AND NOT TO BE PROPOSED DWELLING FOOTPRINT ` USED FOR LOT LINE STAKING. T.F. 18.50' 8. PIPE FOR SEPTIC SYSTEM TO SCH. 40-4 PVC. UTILITY r ti `\ \• " CP , ' POLE �'J Y O _ 2 TH1 CP �O ' 9. COMPONENTS NOT TO BE BACKFILLED OR CONCEALED WITHOUT n >KU L A. v . ',) rAINED ass _ W�R�S 21 FROM BOARD OF HEALTH, 21 CHEF? ES S 6632 166 O, 10. CONTRACTOR SHALL BE RESPONSIBLE FOR -VERIFYING THE LOCATION OF ALL UNDERGROUND & OVERHEAD UTILITIES PRIOR 1 BRF EXISTING COTTAGE TO BE COTTAGE �' _ ' rn 'S I PROP. WELL , TF=23.37' � � -'"1 ss' w�� TO COMMENCEMENT OF WORK.. RENOVATED - �„p - I EXISTING C .+ #4 \' \ UTILITY ( L - FOOTPRINT ��G� DWELLING SATE AND SEWAGE PLAN �F '�.� ,.,\ --- ___ ' � �\� �,�,,. °F 192 MEADOW LANE. . A, x __ ,I � -gs EXISTING POOL TO BE FILLED IN AND ' S S6 OR x \x '\`" `` ' GARDEN TO B PLANTED IN ITS PLACE .� IN THE TOWN OF: 4 S , •O Q \ / � , (WEST) BARNSTAE�LE � Q �, '\ \, POOL 4C" PREPARED FOR: �1J J F E FRf WY MAN 1 ES W MAN L3°.8 A R EST / #6 Area = 165,501 sq.ft TOTAL � G�' �p 40 0 40 80 120 UPLAND SHED TO ��w #7 Area = 133,009 sq.ftf BE REMOVED) 3.05 Acres PROP. SCALE: 1 = 40' DATE: - NOVEMBER 9, 1998 WETLAND SS�•��9e Area = 32,492 sq.ftf #8 0 , 0.75 Acres O, F /; !NE F oOFNOTE: ALL WORK IS GREATER THAN 400' TO SMITH CREEK H' ��,, o��� ARNE s��y & o�w.� c #15 O �, � � $ CIVIL n � H. � • - CESSPOOLS ARE TO BE PUMPED AND FILLED WITH CLEAN SAND (OR REMOVED) 30792 q O,IALA .28348 NO COASTAL `BANK EXISTS, EITHER STATE DEFINITION OR TOWN OFb EG�STE ,�� o #14 J BARNSTABLE DEFINITION, ON SITE AR _ OJALA, s' �.5. DATE #9 , - #12 FLOODZONE ELEV. 11 .0 WAS STAKED IN THE FIELD AND LOCATED HEREON EXISTING DWELLING TO BE DEMOLISHED AND FOUNDATION REMOVED WITH s '0s #1 1 #10 ALL MATERIALS DISPOSED AT AN APPROVED SITE. S3, •2S 2g, VISTA PRUNING PLANNED UNDER DIRECTION OF CONSERVATION Soy AD M I N I STRATO R ELEVATION 11.0' WAS STAKED IN THE FIELD WITH HAND-LEVEL 169.56 COMP TRANSECTS PERFORMED ABOVE AND BELOW THIS ELEVATION. N0 - N 88'T7'16 E LINE SLOPES MEASURED GREATER THAN 18% (T���'N R�G'vLATION) AND NO Ss 0, SLOPES MEASURED GREATER THAN 10% (STATE REGULATION). S29 SO„ off 508-362-4541 I fox 508 362-9880 I� down cape engineering, Inc. CIVIL ENGINEERS i LAND SURVEYORS 939 main st. yarmouth, ma 02675 98- 142 PROP. HOUSE SEPTIC PROFILE LEGEND T.O.F. AT EL. 18.50' TEST TA•i')LE LOGS E ACCESS COVER TO WITHIN 6" OF FIN. GRADE (NOT TO SCALE) 100.0 PROPOSED SPOT ELEVATION SEPTIC DESIGN: (GARBAGE DISPOSER IS NOT ALLOWED ) I 0 /17. ACCESS rOVER (WATERTIGHT) TO A.H. ^!,�I�, PE � WITHIN .' OF FIN. GRADEENG►NEER:DESIGN FLOW: 5 BEDROOMS (L 1?�GPD) = 550 GPD 0 MINIMUM .75' OF COWER OVER PRECAST 2% SLOPE REQUIRED OVER SYSTEM 17.0' J. DUNNING 100x0 EXISTING SPOT ELEVATION USE A 550 GPD DESIGN FLOW WITNESS: • HOUSE RUN '-JIPE' LEVEL 2" DOUBLE WASHED PEASTONE DATE; 10/20/98 !- 100 SEPTIC TANK: 550 GPD (2_) = 1 100 15.5' /'-FOR ."If?S'i 2' - I o- PROPOSED CONTOUR PROPOSED 1 500 <; 2 MIN/INCH USE A 1�0C GALLON SEPTIC TAI\'K 3 MAX. PERC. RATE 100 EXISTING CONTOUR GALLON SEPTIC 14.91 ' - -4--i � I LEACHING: AA REQUIRED = FLOW/0.75 15.16' TANK (H- 10 ) GAS Q, 14.0' CLASS I S. iLS P# , " 3.5_ +► r TREE 734 SQ. FT. = 550 / 0.75 BAFFLE 13:76 Y > ° 9 HIGH CAPACITY - � 0 13.27 f 4' ® SIDES (56.25 + 4 + 1) x (3 + 4. + 4 + 1) = 735 SF ( 2 % SLOPE) �6" CRUSHED NONE OR MECHANICAL COMPACTION. (15.221 [2]) $ 0 91' INFILTRATORS o 12.36' 1 - 2 ELEV. l f TOTAL: 735 S.F• 551 GPD DEPTH OF FLOW = 4 ( 1 % SLOPE) p" Q 20,29' 0" Q 18.84' ' USE 9 HIGH CAPACITY INFILTRATORS WITH 4' OF TEE SIZES: 3/4 TO 1 1/2 DOUBLE WASHED STONE A f„ STONE AT SIDES AND 2' AT ENDS (NONE UNDER) INLET DEPTH = 10" P qp „P - OUTLET DEPTH = 1 4" LS M LS j 5 1 2 8> 10 YR 3/4 10YR 4/4 LOCATION MAP SCALE 1" _ �t4 fig, FOUNDATION- 17' SEPTIC TANK 1 1.5' - - -- D' BOX 32' LEACHING Bw 12" FACILITY Bw ASSESSORS MAP 158 PARCEL 5-4 LS FS ZONING DISTRICT: RIF BOARD OF HEALTH „ i OYR 6/8 30„ 1 OYR 5/8 , , MA 34 1 7 46 16.34 YARD SETBACKS: �; APPROVED DATE EXIST. COTTAGE FRONT = 30' ' ADJ, WATER ® 7.24' T.O.F. AT EL. 23.37' r C I C SIDE = 15' REAR = 15' 21 .0' FS FS PLAN REF. MINIMUM .75' OF COVER OVER PRECArl a a ` WELL: SDW 252 FLOOD ZONE: A5 EL 11 AND C 5 �o° 19.5' ZONE. A 2.5Y 7/6 2.5Y 5/3 (HOUSE RESIDES IN FLOOQZONE C) PROPOSED 1500 ADJ.: 1.4' GALLON SEPTIC I I 19.0 19.25' TANK (H- 10 ) GAS 5 84' BAFFLE 156 �bs. water Q` ( 2.5% SLOPE) �6" CRUSHED STONE OR h;ECHANICAL \/ COMPACTION. (15.221 [2].' 120" 10 29' 168" 4.84' I \ \`\ AUGER HOLE RESULTS (UNWITNEESSED, PERFORMED 4/21/98) 5-F, 0 - 3" 0 & A NOTES: 160�° \`\ AUGER HOLE 3 - 12" Bw1 FINE SAND 2.5Yf 5/4 NGVD 1 . DATUM IS (4/21/96) ;2 - 33" Bw2 FINE SAND 2.5Y 6/6 10' 2. MUNICIPAL WATER IS NOT AVAILABLE 3" - 60" Cl FINE SAND 2.5Y 6/6 �FSF 3. MINIMUM PIPE PITCH TO BE 1/8" PER FOOT. 60" - 122" C2 FINE SAND 2.5Y 6/4 \ I 4. DESIGN LOADING FOR ALL PRECAST UNITS TO- BE AASHO H-10 \ " WATER ENCOUNTERED AT 113' ) 5. PIPE JOINTS TO BE MADE WATERTIGHT. TH2 'EL. 7.14' 6. CONSTRUCTION DETAILS TO BE IN ACCORDANCE WITH MASS. ' #2 ZONE: a ENVIRONMENTAL CODE TITLE V. T 0�' WELL: SDW 252 7, THIS PLAN IS FOR PROPOSED WORK ,ONLY AND NOT I 0 BE \`V, PROPOSED DWELLING FOOTPRINT \ v FOR STAK USED 0 LINE NG y / +n.. - -__. .. ,�„-/ r ,G CI-DTI/`NC r•�rri I T/.. f f• U A , UTILITY . . _c -- 8. r G. �Y� „ ,. D 2 �H1 / , - CP �� CP 9. COMPONENTS NOT TO BE BACKFILLED OR CONCEALED WITHOUT o \ �.� O INSPECTION 21 BY BOARD OF HEALTH AND ,PERMISSION OBTAINED Ao• ss RFS \ \` s4 FROM BOARD OF HEALTH. 8 21 CHER ES 6632,'66 !�;� 10. CONTRACTOR SHALL BE RESPONSIBLE FOR VERIFYING THE LOCATION OF ALL UNDERGROUND & OVERHEAD UTILITIES PRIOR TO COMMENCEMENT OF WORK. F t BR .� � '� ,. � � �, /s I PROP. WELL F � ' EXISTING COTTAGE TO BE COTTAGE RENOVATED TF-23.37' EXISTING #4 UTIUTY L _ _ I DWELUNG S17E AND SEWAGE PLAN POLE r _ , FOOTPRINT �X X `� ; L-\1 EXISTING POOL T BE FILLED IN AND � OF 1 J 2 MEADOW LAN E Q \ tO , ' , GARDEN TO B PLANTED IN ITS PLACE . Ss,A96os QQ° x -� � I, _ _- _ _ -� ��; IN THE TOWN OF: /61 co (WEST) BARNSTABLE LOT 1 B \.\ � POOL w' .,' PREPARED FOR: '� JEFFRIES .. WYMAN 3.8 ACRESt Area = 165,501 sq.ft TOTA� 40 0 40 80 120 UPLAND SHED (TO Area = 133,009 sq.ftt BE REMOVED) as oP� #7 3.05 Acres PROP. SCALE: 1 = 40' , ' DATE: NOVEMBER 9, 1998 �VETLAN D ss���se Area = 32,492 sq.ftf 8 I 09• 0.75 Acres # ,�O soya OF O J �0 15 G' ' �,'� NOTE: ALL WORK IS GREATER THAN 400' TO SMITH CREEK o'�� ARNE H. s� ��`1N of ,yc9 OJALA S CESSPOOLS ARE TO BE PUMPED AND FILLED WITH CLEAN SAND (OR REMOVED) S ARNE H. av2 8 OJALA .26348 4 \ NO COASTAL BANK EXISTS, EITHER STATE DEFINITION OR TOWN OF E�ISTE \��``� � #14 BARNSTABLE DEFINITION, ON SITE -� - ---- ' ° / 9� -_- J #9 AIR OJA LA, �f . S. DATE #12 FLOODZONE ELEV. 11 .0 WAS STAKED IN THE FIELD AND LOCATED HEREON #13 #10 EXISTING DWELLING TO BE DEMOLISHED AND FOUNDATION REMOVED WITH s 'oe #1 1 ALL MATERIALS DISPOSED AT AN APPROVED SITE. S3?9 ?s VISTA PRUNING PLANNED UNDER DIRECTION OF CONSERVATION so„ F ADMINISTRATOR ELEVATION 11.0' WAS STAKED IN THE FIELD WITH HAND-LEVEL 169.56 COMP TRANSECTS PERFORMED ABOVE AND BELOW THIS ELEVATION. NO N 88-17'16' E LINE SLOPES MEASURED GREATER THAN 18% (TOWN REGULATION) AND NO Sss s,00 SLUI'CS MEASURE-, GRREATER THAN 10% (STATE REGULATION). 29; S0, ' F off 508-362-4541 fox 508 362-9880 down , cape engineering, Inc. CIVIL ENGINEERS LAND SURVEYORS 939 main st. yarmouth, ma 02675 98- 142