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HomeMy WebLinkAbout0298 PARKER ROAD - Health 298 Parker Road West Barnstable / A= 176-012 w i 1 `I Massachusetts Department of Environmental Protection Bureau of Resource Protection GENERAL WELL REPORT Note:GPS coordinates must be in WGS84 datum in degrees. decimal degree format. 1.WELL LOCATION GPS(Required) North West Address at Well Location:v-'- TKProperty Owner Subdivision/Property Description I ❑Engineering Firm 2�2 ?,A _Ab, City/Town ;' tV�7i{ &64 Mailing Address - Assessors Map L7 10 Assessors Lot# �`�- Cityrrown State Q2-6 Board of Health permit obtained Yes ❑Not Required Permit Number (,[)r 2613^624 -Date Issued '-IOLU113 2.WORK PERFORMED> 3.WELL TYPE 4.DRILLING METHOD 6.:ADDITIONAL WELL INFORMATION ®burden B❑edroc❑k p EN Y-❑N Fracture Y ®N Develo ed Enhancement 5.WELL LOG OVERBURDEN LITHOLOGY Extra Drop in Loss or Surface Seal Fast or Disinfected W Y ❑N IM R From To Drill Slow Addition Type Code Color Comment Stem of Fluid (ft) (ft) Drill Rate Total Well a Depth to v1)(1;..- ❑Y ❑N ❑F ❑S ❑L ❑A Depth 39d, Bedrock 1 Cl- ❑Y ❑N ❑F ❑S ❑L ❑A 7.CASING A— - -- ❑Y ❑N ❑F ❑S ❑L ❑A From To_. .__Type Thickness Diameter 1� Sig i A, El ❑N ❑F ❑S ❑L ❑A 0 -3 , 54W 4,0 Ve ✓L '3� P16 fZt. W F_j ❑Y ❑N ❑F ❑S ❑L ❑A ©�® CL WZ ❑Y ❑N ❑F ❑S ❑L ❑A 8.SCREEN .` ❑Y ❑N ❑F ❑S ❑L ❑A From To Type Slot Size Diameter ❑Y ❑N ❑F ❑S ❑L ❑A `311i, 3S-6 aaEE . 0 5.WELL LOG: BEDROCK LITHOLOGY Extra ❑❑� Drop Extra Fast or Loss or Visible —— From To In Drill Large Slow Addition,. Rust 9.WATER-BEARING ZONES (ft) (ft) Code Comment Stem Chips Drill of Fluid Staining r Rate From To - •Yield m (gP ) ❑Y.❑N❑Y❑N❑F❑S,❑L❑A❑Y❑N c. 3S ❑Y❑N❑Y❑N❑F❑S[3L[1A❑Y❑N ❑Y❑N❑Y❑N❑F❑S❑L❑A❑Y❑N ❑Y❑N❑Y❑N❑F❑S❑L❑A❑Y❑N 10.PERMANENT PUMP(IF AVAILABLE) _ ❑Y❑N❑Y❑N❑F❑S❑L❑A❑Y❑N pump OI�U S Horsepower ❑Y❑N❑Y❑N❑F❑S❑L❑A❑Y❑N.Description l�U ®r ❑Y❑N❑Y❑N❑F❑S❑L❑A❑Y❑N Pumpintake Nominal ❑Y❑N❑Y❑N❑F❑S❑L❑A❑Y❑N Depth 3 Pump In _ ft Capacity �_gpm 11.ANNULAR-SEAL(FILTER PACK. ' 12:GEOTHERMAL INFORMATION(Opt;Open Loop only) From To Material 1 Weight Material Weight Water(gal) Batches Method of Thermal Thermal Formation Placement Conductivity Diffusivity Water 0. ( (BTU/hr•ft•°F) (f?/day) Temperature(°F) DEP UIC# Sample taken from this well❑Y ❑N 13.WELL TEST DATA 14:WATER LEVEL Date Method Yield(GPM) Time Pumped Pumping Level Time to Recover Recovery Date Static Flowing (hrs) (min) (ft BGS) (hrs) (min) (ft BGS) Measured Depth BGS(ft) Rate(gpm) 0 5' 241E 1z.i eS t 9 ❑ ❑ 15.COMMENTS This well was drilled or altered under my direct s ervis according to the applicable rules and regulations,and this 16:WELL DRILLERS STATEMENT report is complete and accurate to the b of my k wled e. Driller 72 ,- A Supervising Driller Signature -/ GG/o4­1 '- Certification# Company ` �`6 (��,/L((g Q.tjtij Date Job Complete L 3 Rig Permit# ENVIROTECH LABORATORIES,INC. MA CERT.NO.:M-MA 063 8Jan Sebastian Drive Unit 12 Sandwic/t,A9A 02563 (S08)888-6460 1-800-339-6460 FAX(508)888-6446 Client Nante Atlantic 1 fell Drilling Location 298 Parker Rd. Address PO Box 339 W.Barnstable,MA No.Eastham MA 02651 Sample Date 12/17113 Collected By R.Peterson Sample Tinte 13:00 Sample Type New Well Date Received 12/17/13 Lab Order Number DW-134105 Well Specs 35.5717.5'Static LocaB©t:Source bale Collected Tttrie Collecle�jflmjn�n�: :_. 117h3 93�OQ. . _ Analysis Requesfed Units Recominentled Litults Analysis Result AfeNtod Date Analyzed Analyzed By Total Coliform /100ml 0 0 SM9222B 12/17/2013 RS ---..__......— _.....----—--... ...—- -----... .. - --- .......... - pH pH units 6.5-8.5 5.79 SM4500 H B 92/17/2013 !! Specific Conductancen umhos/cm 500 260 EPA 120.1 12/17/2013 LL Nitrite-N mg/L 1.00 <0.004 EPA 300.0 12/17/2013 LL Nitrate N mg/L 10:0 1.10 EPA-300.0-- 12/17/2013 !L Sodium mglL 20.0 34.9 EPA 200.7 12119/2013 MC Total Ironn mg/L 0.3 0.12 EPA 200.7 12/1...... MC Manganesen mg/L 0.05 0.008 EPA 200.7 12/19/2013 MC Volatile Organic Compounds` ug/L See comment. None Detected. EPA 524.2 12/2012013 NEC' Comments: Low pH indicates high corrosive characteristics. Sodium level is not a health hazard. Water meets EPA standards and is suitable for drinking for parameters tested. .-- ---Date oial .Saari' Laboratoty�D rec or BRL=Below Reportable Limits *See Attached Page 1 of 1 aCerlii icatlon is not available for this analyte for non potable water samples.. New.Engl and.-ChromaChem- 6 Nichols Street Salem,MA 01970 978-744-6600 Massachusetts DEP Lab.MA-072 Sample Information EPA Method 524.2 Rev 4.1 Volatile Organic Compounds In Water Lab ID: 312123 Client: Envirotech Laboratory,Inc. Client ID: DWA34105 State:. Liquid Date Sampled: 12/17/13 Date Received: 12/20/13 Date Analyzed: 12/20/13 MCL Regulated VOC's Results(ug/L) (uglL) Unregulated VOC's Results(uglL) Benzene ND 5 Acetone ND Carbon Tetrachloride ND 5 Bromobenzene ND 1,i-Dichloroethene ND 7 Bromochloromethane ND 1,2-Dichloroethane ND 5 Bromodichtoromethane ND 1,2-Dichlorobenzene ND 600 Bromoform ND 1,4-Dichtorobenzene ND 5 Bromomethane ND Trichloroethene NO 5 2-Butanone ND 1;1;1=Trchloroethane ND -200 N-Butylbenzene ND Vinyl Chloride NO 2 Sec-Butylbenzene ND Chlorobenzene ND 100 Tert-B benzene ND cis-1,2-dlchloroethene ND 70 1 Chloroethane ND trans-12-dichioroethene ND 100 Chloroform ND 1,2-Dichloro ro ane ND 5 Chloromethane ND Ethylbenzene ND 700 2-Chlorototuene ND Styrene ND 100 4-Chlorototuene ND Tetrachloroethene ND 5 Dibromochloromethene ND Toluene ND 1000 1,2-Dibromo-3-Chloro ro ane ND X enes otal ND 10000 1,2-Dibromoethane ND Methylene Chloride ND 5 Dibromomethane ND 1,24-TdcNorobenzene ND 70 1,3Dlchiorobenzene ND 1,1,2-Trichloroethane ND 5 Dichlorodiftuoromethane ND 1,1-Dlchloroethane ND 1 3-Dichloro ro ane ND 2 2-Dichloro ro ane ND I,I-Dichloropropene ND Hexachlorobuladlene ND Iso ro benzene ND P-Isopropyltoluene ND Methyl-tert-butyl ether ND Naphthalene ND N-Propylbenzene ND 1,912-Teirachloroelhane ND 1,1,2,2-TetracNoroethane ND 1,2;3-Trichlorobenzene ND Trichloroftuoromethane IND 1,2 3-Trlchior ro ane I ND 1,24-Tdmeth benzene IND 1,3.6-Trimethylbenzene IND Method Detection Limit=0.5 u Recoveries of Internal Standards % Benzene-d6 106 4-Bromofluorobenzene 94 MCL TTHM's=80 ug/L 1 2-Dichlorobenzene-d4 1112 Method Deteciion Limit=0.6 ug/L Analysis performed per 310CMR42 Electronically signed and approved by Mr.Bruce A.Bornstein,Lab Director Date: 12/23/2013 i No. Fee /'T• , BOARD OF HEALTH TOWN OF BARNSTABLE 2pplicatiou ,for Yell Cou0tructiou 3permit Application is hereby made for a permit to Construct , Alter( ), or Repair( ) an individual well at: •�f/.Loocattioonn-Address Assessors M/a'p�a�nd Parcel ^ _S..l./t�C�✓V 'i�.1&VJ` rA'�/��' Owner 666 Address �2�0 C_ UY&Z-,� 44ccP�✓��� � 40 l&c Mo 41, Installer-Driller Address Type of Building / Dwelling �/ Other-Type of Building No. of Persons Type of Well tDo-CA/1�L� Capacity Purpose of Well at'( .;6J,61el— Agreement: The undersigned agrees to install the afore described individual well in accordance with the provisions of the Town of Barnstable Board o fH h e Well Protection Regulation-The undersigned further agrees not to place the well in operation until a Certificate o mpli n has been issued by the Board of Health. Signed l� Dat Application Approved By Date Application Disapproved for the following re s: �^ Date Permit No. Issued Date ;ra No. �� Fee 7 s. BOARD OF HEALTH TOWN OF BARNSTABLE 2ppficatiou _for Yell Cou24ructiou Permit Application is hereby made for a permit to Construct Alter( ), or Repair( ) an individual well at: (Cuel2 (76 - a1 2-. Location-Address Assessors Map and Parcel Owner Address A,rb�-kqcc t if 1 t Lc��✓GF�',cr 4 ►�DX 33�i. �(/, G-ff�f C, Gl,� a�G r Installer-Driller Address Type of Building ` Dwelling Other-Type of Building No. of Persons Type of Well 7d L�/�L� Capacity Purpose of Well Agreement: The undersigned agrees to install the afore described individual well in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation-The undersigned further agrees not to place the well in operation until a Certificate of mp Il nee has been issued by the Board of Health. / Signed i / ld 29 / a Da Application Approved By �G''"! `-=✓ /D t yi 1 /Date Application Disapproved for the following reaswns. F Date ram" Permit No. �/ Issued Date BOARD OF HEALTH TOWN OF BARNSTABLE Certificate of Compliance ' 1 THIS IS TOR/�Y,that tle individual vVell Gonstrucfed, ltered( ), or Repaired by Installer at has been installed in accordance with the provisions of the Town of Barnstabl• Board of Healtb Private Well Protect* Regulation as described in the application for Well Construction Permit No. 3_ Dated /� f r" / — / THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORILY. Date `7 �>l /I Inspector /l//!/✓J, _,, �� I v BOARD OF HEALTH TOWN OF BARNSTABLE VCU Con.9tructiou permit No. 040-L3 A -,I 1A & Fee Permission is hereby granted to l L11/ �' � / C, Installer to Construct( ), A�lfter O or Repair( an iin•ividual Jwlll�,at: No. �! 15 '! � 7J 0 nP. �` �J �� l t f Street d [VZ/,5�0Wj)atedas shown on the application for a Well Construction Permit No. Date / Approved By Map; Page 1 of 1 Town of Barnstable Geographic Information System New Sear Parcel Viewer Custom Map Abutters Map Size ® Zoom Out In[3 3PG Map: 176 Parcel: 012 177002 Location: 298 PARKER ROAD 00 Owner: BELIFORE,COLLEEN A 170023 X 212 Location Information Map&Parcel 176012 Location 298 PARKER ROAD 177001 Acreage 1.30 acres XO Current Owner ------------------------------ Mailing Address BELIFORE,COLLEEN A 176015 298 PARKER ROAD 0240 WEST BARNSTABLE,MA I ,g�a1 Appraised Value(FY 2013) �. 17801*4 Extra Features $17,300 N204b Out Buildings $5,700 �.,.. ® Land $244800 17001 Buildings $117:700 �p 292 i 12 'a3r Total Appraised $385,500 N2eegO (G PA I _Assessed Value(FY 2013) Extra Features $ 00 UCy�' Out Buildings $5,70700 179018 Land $244,800 t0320 ?M� X245 Buildings $117,700 6 Total Assessed $385,500 v Construction Detail Style Cape Cod Mode[ Residential 170028 178010 Y316 Grade Average 0400 Stories 1 1/2 Stories Exterior Wall Wood Shingle 176019 Roof Structure Gable/Hip 0301 Roof Cover Asph/F GIs/Cmp 170020- Interior Wall Typical ST X333 0y1 ! 1700I0001 Interior Floor Hardwood 0 f47 Feet! N 161 Heat Fuel Oil - 176021 Heat Type Hot Water N463 Y301 AC Type None Number of 3 Bedrooms Set Scale 1"= 147 I Aerial Photos I MAP DISCLAIMER Bedrooms Copyright 2005-2010 Town of Barnstable.MA All rights reserved.Send questions or comments to GIS BarnstableMA v1.2.4748[Production] http://66.203.95.236/arcims/appgeoapp/map.aspx?propertyID=176012 10/29/2013 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 298 Parker Road Property Address Colleen Belifore Owner Owner's Name information is West Barnstable MA 02668 March 22, 2010 requ red for State Zip Code Date of Inspection every page. Cityrrown Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Important: A. General Information When filling out forms on the computer,use 1. Inspector: only the tab key to move your Patrick M. O'Connell cursor-do not Name of Inspector use the return key. Septic Inspection Services Co. Company Name 189 Cammett Road Company Address Marstons Mills MA 02648 Cityrrown State Zip Code 508428-1779 SI 12855 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—fiction 15,.-40 of--j Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ 55il ❑ Needs Further Evaluation by the local Approving Authority _w March 22, 2010 --- 1�— ector's S nature 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. 10-71 Bel fore.doc•08/06 Title 5 Official Inspection Form.Subs a.e SAG �is s System•Page 1 of 15 i Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 298 Parker Road Property Address Colleen Belifore Owner Owner's Name information is West Barnstable MA 02668 March 22, 2010 required for every 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: Recommend pumping tank, leaching system shows no signs of surcharge or hydraulic failure. B) System Conditionally Passes: El One or more system p r stem 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. Answer yes, no or not determined (Y, N, ND) in the ❑ for the following statements. If"not determined," please explain. ❑ The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed i10-71 BelHore.doc•08f06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 298 Parker Road Property Address Colleen Belifore Owner Owner's Name information is west Barnstable MA 02668 March 22, 2010 required for State Zip Code Date of Tinspection every page. Cityrrown B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: I ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ND Explain: 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 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. 10-71 Belifore.doc-08/06 Title 5 Official Inspection Form.Subsurface Sewage Disposal System-Page 3 of 15 i '-�C\, Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 298 Parker Road Property Address Colleen Belifore Owner Owner's Name information is West Barnstable MA 02668 March 22, 2010 required for every page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: I 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 ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: Cl ® 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. 10-71 Belifore.doc•08106 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 4 of 15 '_<L\ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 298 Parker Road Property Address Colleen Belifore Owner Owner's Name information is West Barnstable MA 02668 March 22, 2010 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® 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 CM 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. I 10-71 Belifore.doc-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 15 '_<C_\ Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 298 Parker Road Property Address Colleen Be1fore Owner Owner's Name information is regeired for West Barnstable MA 02668 March 22, 2010 every page. City/Town 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)] :0-71 Belifore.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 Commonwealth of Massachusetts ' . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments p Y 298 Parker Road Property Address Colleen Belifore Owrer Owner's Name information is required for West Barnstable MA 02668 March 22, 2010 every page. Citylrown State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 1 Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No N/A Well Water Water meter readings, if available(last 2 years usage (gpd)): Sump pump? ❑ Yes ® No Currently Last date of occupancy: Occupied. 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: Last date of occupancy/use: Date Other(describe): 1:0.71 Belifore.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 298 Parker Road Property Address Colleen Belifore Owner Owner's Name information is required for West Barnstable MA 02668 March 22, 2010 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: None Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of 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) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: Leaching system installed in 1998 Were sewage odors detected when arriving at the site? ❑ Yes ® . No 10-71 Belilore.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 r� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments N 298 Parker Road Property Address Colleen Belifore Owner Owner's Name information is required for West Barnstable MA 02668 March 22, 2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): 2' 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): 3" Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No •---------------------------------------------------- ---------------- --------------------------------------------------- Dimensions: 8.5' long x 5.2'wide- 1000 gal. 4" Sludge depth: 26 Distance from top of sludge to bottom of outlet tee or baffle 3" Scum thickness Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 10" How were dimensions determined? Measured 10-71 Belifore.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 298 Parker Road Property Address Colleen Belifore Owner Owner's Name information is West Barnstable MA 02668 March 22, 2010 required for every 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.): Baffles were intact and liquid level was found at bottom of outlet invert. Recommend pumping tank. 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 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): 10-71 Belifore.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,.' 298 Parker Road Property Address Colleen Belifore Owner Owner's Name information is regt.ired for West Barnstable MA 02668 March 22, 2010 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank (cont.) Dimensions: Capaci ty 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 Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): No solids or high stains present, liquid level was found at bottom of outlet inverts. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 10-71 Belifore.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 298 Parker Road Property Address Colleen Belifore Owner Owner's Name information is West Barnstable MA 02668 March 22, 2010 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: Two 6x6 pits. ® leaching chambers number: 6 Infiltrators. ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching pits are still connected to system, however had previously been in failure and were not opened Updated leaching system was probed with no evidence of saturation. 10-71 Belifore.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 ' Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 298 Parker Road Property Address Colleen Belifore Owner Owner's Name information is required for west Barnstable MA 02668 March 22, 2010 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 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 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.): 10.71 Belifore.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 Commonwealth of Massachusetts TRife, 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments kiwi 298 Parker Road Property Address Colleen Belifore Owner Owner's.Name information is required for West Barnstable MA 02668 March 22, 2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. . . . . . . . . . . . . . T T T-T-T. . . . . . . . . . . . . . . . 2 .. . . . . . .. . . . . . . . . . . . . . . . ----Rear- 96 80 13 126 164 .......... ......................... ................................... . .................................. .. X X. ................. .... f Commonwealth of Massachusetts li Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 298 Parker Road Property Address Colleen Belifore Owr:er Owner's Name information is required for west Barnstable MA 02668 March 22, 2010 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells 8-10+/- Estimated depth to ground water: feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site(abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: As-built card on file ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: Low areas of adjacent properties with no surface water are lower in elevation than bottom of SAS. as- built card specified water 6 feet below system. 10-71 Belifore.doc•06/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 1 *. . -' TOWN O STABLES LOCATION T SEWAGE # VILLAGE ASSESSOR'S MAP & LOT /7G 0l INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) . /O V � NO.OF BEDROOMSv BUILDER OR OWNER PERMTTDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) ��� Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by + , C go .AQO , No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 0[pprication for Di!5po5a1 6potem Congtruction Permit Application for a Permit to Construct( )Repair( .Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Lo�Cation�Addres Lot No. I-�� _ 7 er SnName,Address and Tel.No. Assessor's Map/Parcel ��c/_ ��' ( Cr2'y�"' 7C - d Z Installer' Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms 3 Lot Size ml 3�criP�lft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank /0 vO t' Type of S.A.S. Description of Soil Naturef Repairs or Alterations(Answer when applicable) % G lU Date last inspected: Agreement: The undersigned agrees to ens a construction and maintenance of the afore described on-site sewage disposal system in accordance with the provision of Title of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been iss ed by t is oard ealt Signed Date /L ' S lq F Application Approved by Date 10 Application Disapproved for a following reasons Permit No. Date Issued i TOWNZQ S TABLE p LOCATION �. SEWAGE # VILLAGE ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. tI SEPTIC TANK CAPACITY LEACHING FACIL=: (type)` NO.OF BEDROOMSv BUILDER OR OWNER �S PERMrrDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table:to the Bottom of Leaching Facility 1 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 f - Pr Ca rI J� .. h � � No. Fee �- THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: �y< Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS 3ppiication for Mi-4poeal *pztem Construction Permit Application for a Permit to Construct( )Repair( .Upgrade( )Abandon( ) O Complete System ❑Individual Components Location Addres Lot o. wner's,Name,Address and Tel.No. Assessor's Map/Parcel G - of 2— Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. J Wig_ Type of Building: Dwelling No.of Bedrooms Lot Size /.3S a ft. Garbage Grinder( ) Other ,Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank /o vG <' Type of S.A.S. f f Description of Soil r 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 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been iss ed by th's oZoealt q Signed Date /y ' S'< Application Approved by Date /e - .9- -217 Application Disapproved for tis6 following reasons Permit No. 7a - Gi Y6 Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of (Compliance THIS IS TO CERPit the On-site Sewage Disposal System Constructed( )Repaired (�)Upgraded( ) Abandoned( )by ."'" -,,._ at 2 S has been construofe(&na�ord?M_ with the provision_s f Title 5 and the for Disposal System Construction Permit No. t'D Y6 dated Installer - W f'`^-' Designer The issuance of this permit shall not be construed as a guarantee that the system will function as designed. Date 1 -a�9 - Inspector ---q------------------------------------ No. Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Migoar 6p6tem Construction Permit Permission is hereby granted to Cons ct( )Repair( pgrade( )Abandon( ) System located at 2 17_ A;cZ J A 41 4V 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 be completed within three years of the date of this permit. Date: //7 - Approved by I)k -ID 10/9197 NOTICE: This Form Is To Be. Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT ENGINEERED PLANS) 019 1, lbo--� , hereby certify that the application for disposal works construction permit signed by me dated �dA � , concerning the property ert located at ;— 179 A1'4 /V iU'F eets all of the following criteria: • There are no wetlands located within 100 feet of the proposed leaching facility • There are no private wells within 150 feet of the proposed septic system • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. • If the proposed leaching facility will be located within 250 feet of any wetlands, the bottom of the proposed leaching facility will=be located less than fourteen (14) feet above the maximum adjusted groundwater table elevation. Please complete the following: L A)Top of Ground Elevation(according to the Engineering Division G.I.S. map) B)Observed Groundwater Table Elevation(according to Health Division well map) a S SIGNED : -s"� DATE: LICENSED SEP C SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER [Attach a sketch plan of the proposed system.Also if the licensed installer posesses a certified plot plan, this plan should be submitted]. q:health folder:cent x� 1v i`� �w4� �. C�D X (o kZ -- -- ,1 ~ TOWN OF ARNSTABLE LOCATION -1 Pc,c Iutr SEWA-EiE# :-y1 Se VILLAGE OJ `mod/� ASSESSOR'S MAP&PARCEL �'S NAME&PHONE NO. v-'_c,' �- O/1✓lQ / �(' SEPTIC TANK CAPACITY /OCR LEACHING FACILITY.(type) ,�rl'P I�r ��s (size) NO.OF BEDROOMS OWNER ell. 4e PERMIT DATE: C0dMDMX9a DATF_7=,n5 P �/ /K) 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 NO feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet 4 FURNISHED BY 4 ti \ 4 \ � \ 4 k \ \ • 'w \ k \ 1 \ 4 4 \ \ \ 4"4 ti \ v I � - k \ \ k 1 1.1 ti'\ 4 1 1 .♦ 'ti � 1 1 1 \ \ 1 � \ \ k ti �. \ ""`..�T Rear 96 80 13 - 126 164