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HomeMy WebLinkAbout0138 PLUM STREET - Health 138 Plum Street W. Darnstablc _ A = 195 036 d 'I Commonwealth of Massachusetts 03(p Title 5 Official Inspection Form la Subsurface Sewage Disposal System Fo rm Not for Voluntary 9 p Y ry Assessments 138 Plum St Property Address Rogers Randolph E and Anastasia M Owner Owner's Name information is W Barnstable Ma required for every p2668 9/23/19 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 A. Inspector Information filling out forms on the computer, use only the tab Michael DiBuono key to move your Name of Inspector cursor-do not DiBuono Sewer And Drain use the return Company Name key. 35 Content Lane rab Company Address Cotuit Ma 02635 City/Town State Zip Code rsrcva 508-364-9587 S113522 Telephone Number License Number i B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 9/25/19 Inspector'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 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 form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: 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. Lt5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18 Commonwealth of Massachusetts 1p Title 5 Official Inspection Form to Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 138 Plum St Property Address Rogers Randolph E and Anastasia M Owner Owner's Name information is required for every W Barnstable Ma 02668 9/23/19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) 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 1000 Gallon septic tank as well as an H2O concrete distribution box and 2 500 gallon H2O Chambers in stone 2) 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): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts �n ,(:p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 138 Plum St Property Address Rogers Randolph E and Anastasia M Owner Owner's Name information is required for every W Barnstable Ma 02668 9/23/19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ 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): 3 Further Ev aluation 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. a. 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: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 i Commonwealth of Massachusetts Title 5 Official inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 138 Plum St Property Address Rogers Randolph E and Anastasia M Owner Owners Name information is required for every W Barnstable Ma 02668 9/23/19 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ 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 b. 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. c. Other: 4) 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 l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments v � 138 Plum St Property Address Rogers Randolph E and Anastasia M Owner Owner's Name information is required for every W Barnstable Ma 02668 9/23/19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® 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 Y day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the 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 water supply 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 2000 gpd- 10,000 gpd. ❑ ® 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. 5) 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 CA. 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 I i Commonwealth of Massachusetts Title 5 Official cal Inspection Form la Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 138 Plum St Property Address Rogers Randolph E and Anastasia M Owner Owner's Name information is required for every W Barnstable Ma 02668 9/23/19 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes" to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The j owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes" or"no"for each of the following for all inspections: 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)] t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 138 Plum St Property Address Rogers Randolph E and Anastasia M Owner Owner's Name information is required for every W Barnstable Ma 02668 9/23/19 page. Cityrrown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 3302 Description: Number of current residents: 2 Does residence have a garbage grinder? ® Yes ❑ No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: 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 218 9 ( Y 9 (gPd))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Date t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 138 Plum St Property Address Rogers Randolph E and Anastasia M Owner Owner's Name information is required for every W Barnstable Ma 02668 9/23/19 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 2. 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 Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holdingtank resent? P Yes El 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 below): 3. Pumping Records: Source of information: Not provided Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18 I Commonwealth of Massachusetts �n ,�.p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments •. /` 138 Plum St Property Address Rogers Randolph E and Anastasia M Owner Owner's Name information is required for every W Barnstable Ma 02668 9/23/19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. 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): Approximate age of all components, date installed (if known) and source of information: 8/14/02 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 3 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.): System is vented at the roof line t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts Title 5 Official ' inspection Form la•, Subsurface Sewage Disposal System Form Not for Voluntary Assessments 138 Plum St Property Address Rogers Randolph E and Anastasia M Owner Ow:ner's Name information is required for every W Barnstable Ma 02668 9/23/19 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 2 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) 1000 If tank is metal, list age: years i Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 Sludge depth: 3 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 4" Distance from bottom of scum to bottom of outlet tee or baffle 30" 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.): Tank is at normal level. Tees and or baffles in place at time of inspection t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form;Subsurface Sewage Disposal system•Page 10 of 18 I Commonwealth of Massachusetts IF Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments V 138 Plum St Property Address Rogers Randolph E and Anastasia M Owner Owner's Name information is required for every W Barnstable Ma 02668 9/23/19 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) 7. 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.): 8. 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 El other(explain): Dimensions: Capacity: gallons � Design Flow: gallons per day l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 , ,'�, Commonwealth of Massachusetts ,? Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments • /` 138 Plum St Property Address Rogers Randolph E and Anastasia M Owner Owner's Name information is required for every W Barnstable Ma 02668 9/23/19 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) 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.): I *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Level and at normal level p q rt 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.): I t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts ,I@ Title 5 Official Inspection Form 'j Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 138 Plum St Property Address Rogers Randolph E and Anastasia M Owner Owner's Name information is required for every W Barnstable Ma 02668 9/23/19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. 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. j 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type. ❑ leaching pits number: ® leaching chambers number: 2 4 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system I Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form �a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u 138 Plum St Property Address Rogers Randolph E and Anastasia M Owner Owner's Name information is required for every W Barnstable Ma 02668 9/23/19 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): No sign of failure. No ponding no break out. 12. 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.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 I Commonwealth of Massachusetts Title 5 Official Inspection Form le Subsurface Sewage Disposal System Form - Not for Voluntary Assessments � 1138 Plum St V� Property Address Rogers Randolph E and Anastasia M Owner Owner's Name information is required for every W Barnstable Ma 02668 9/23/19 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) 13. 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.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments .� 138 Plum St Property Address Rogers Randolph E and Anastasia M Owner Owner's Name information is required for every W Barnstable Ma 02668 9/23/19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 9/25/2019 Assessing As-Built Cards TOWN OF BARNSTABLE 1p� LOCATION �3 � '/ SEWAGE# �" VILLAGE bt/ 161,✓w��2. ASSE.SfiOR'S MAP&LOT INSTALLER'S NAME&PHONE NO. �v SEPTIC TANK CAPACITY / LEACHING FACILITY:(type) 4p��I9�`''� (size) NO.OFBEDROOMS _ BUILDER OR OWNER R)IUf/PERMPf DATE: COMPLIANCE DATE: 't 4 r O Z 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 Fumished by � yY . r 6 6f 3r ' �a, ►a4 Bay Q-7, � ; 63. _►a `_ https://townofbamstable.us/Departments/Assessing/Property_Values/HMdisplay.asp?mappar=195036&seq=1 1/2 Commonwealth of Massachusetts Title 5 Official Inspection Form �a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 138 Plum St �V Property Address Rogers Randolph E and Anastasia M Owner Owner's Name information is required for every W Barnstable Ma 02668 9/23/19 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 10+ 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: 8/12/02 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. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts 7, Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 138 Plum St Property Address Rogers Randolph E and Anastasia M Owner Owner's Name information is required for every W Barnstable Ma 02668 9/23/19 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ❑ A. Inspector Information: Complete all fields in this section. ❑ B. Certification: Signed & Dated and 1, 2, 3, or checked ❑ C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist) completed ❑ D. System Information: For 8: Tight/Holding Tank— Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 TOWN OF BARNSTABLE g) 3 LOCATION 57' SEWAGE # '3 VILLAGE L41 &d w ASSE OR'S MAP & LOT /SfINSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY 4072 S 4 LEACHING FACILITY: (type) CSC 40-(A49 (size) NO.OF BEDROOMS BUILDER OR OWNER PERMTTDATE: COMPLIANCE DATE: Z- 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 p �Y d e 0 ' L 6 �c 3r ,a-7P 83 , L`_ e ?- No. (� � J� Fee 1 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS ZippYication for Migool *patent Construction Permit Application for a Permit to Construct( )Repair )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No.j 3 l ► I Owner's Name,Address and Tel.No. � Assessor's Mapj?arcel / �j In ler's N Ce,AddrejAand Tel.No. De�igy�ra 'N i e,Add sand Tel.No. Tyt,r�rlca�, - 02k,3 �✓J` 71�J�, ,�/� v�y�o4 ". y�a5r� Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures 2 Design Flow 330 gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank C (1G Type of S.A.S. Description of SoilconaBei in Nature of Re airs or Alterations(Answ r when poicable) ° ( n 9 Q f Date last inspected: ,,=SIGNING ENGINEER MUST SUPERAI Agreement: NISTALLATION AND CERTIFY IN 1V-17j­- The undersigned agrees to ensure the construction and maintenance of thA4&elydesdh,`,b`d-d ontsite sewwge.&disposal system in accordance with the provisions of T' e 5 of the Environmental Code and not to�pl'ace he�ysteft1 n operation until a Certifi- cate of Compliance has been issued b this B and of He h Signed Date V Application Approved by Date i U 21 Application Disapproved for the follo ing reasons Permit No. 2Oda-- 3C/ ___ Date Issued L U 2 I ' r ` Nd. a� Fee Q ;- e}' a THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: t/", _ ' Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 2pprication for Miopogal 6potem Construction Permit Application fora Permit to Construct( )Repair()()Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No.f�j �(n �e 'A Owner's Name,Address and Tel.No. a Assessor's Map/Parcel Ins er's N e,Address and Tel No. {p Desig is Name,Add, s and Tel.No. /] � e h �2 7 .Pau l I L 4 f . 5 i ren tot75�"o } " to `3 . lino �! - rQ Type of Building: q Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures 2 2� Design Flow 33o gallons per day.~Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title E Size of Septic Tank Jj4 lf-ihr)C1 IWO G.-a__Q1 Type bf S.A.S. l6O9 ,AYJ Descriptidn of Soil �( l { / W Nature of Repairs o Alterations(Answer when applicable) U"AL. n C4IJLJ iQ Q r � th.. 1 , Date lastinjected: Agreement: f The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by.this 'azdf H B oea- Q Signed Jf.C_ a Date Application Approved.by:' Date i ;t a Application Disapproved for the folio mg reasons ! w t A Permit No. 2 Odd- 35�� Date Issued 2 THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS I$TO CERTIFY,that the On= ite Sewage Disposal System Constructed( )Repaired ( )Upgraded��/) . Abandoned( )by e_ 26 ��(� . i at 13 A to C' has been constructed in accordance with the pravisi nns of Title 5 an the for Diposal System Construction Permit No. hu -3 S/ dated /�U Installer_��//f��•����i .� �/J Designer The issuance of this permit hall not be construed as a guarantee that the system/W/ifi 111 tion signed. Date ?.. Inspector --------------------------------------- No. Fee J v THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Oigpoe;ar *p5tem Construction Permit Permission is hereby granted to Consj t( )Re air( )Upgrade}(. ) bandon System located at r/ / e Y�! • �. 1 ! ��lJ r 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. i Date: I rl Approved by '" h•)�, r/. Zk4 e_f TOWN OF BARNSTABLE • .LOCATION SEWAGE # " 3i VILLAGE fit/ �a ASS OR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) .(size) � r�f NO.OF BEDROOMS BUILDER OR OWNER PERMTTDATE: COMPLIANCE DATE: � r d�- • 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 0 lE r i i 6 �r 3r r �j Ig 7 t y— j i CERTIFICATE OF ANALYSIS•�•. Page: 1 Barnstable County Health Laboratory Report Prepared For: Report Dated: 10/8/2009 Susan Phelan Order No.: G0954676 179 Plum St. West Barnstable, MA Laboratory ID#: 0954676-01 Description: Water-Drinking Water Sample#: Sampling Location: Collected: 9/16/2009 Collected by: Customer Received: 9/16/2009 Routine ITEM RESULT UNITS RL MCL Method# Tested Nitrate as Nitrogen ND mg/L 0.10 10 EPA 300.0 9/16/2009 Copper 0.53 mg/L 0.10 1.3 SM 31 1 1 B 10/8/2009 Iron ND mg/L 0.10 0.3 SM 3111E 10/8/2009 Sodium 7.5 mg/L 1.0 20 SM3111B 10/8/2009 Total Coliform A P/A 0 0 SM9223 9/16/2009 Conductance 68 umohs/cm 2.0 EPA 120.1 9/16/2009 pH 6,7 pH-units 0 SM 4500 H-B 9/16/2009 EPA 525.2 -Pesticides ITEM RESULT UNITS RL MCL Method# Tested Alachlor ND mg/l 0.41 0 EPA 525.2 9/24/2P0 Aldrin. ND mg/l 0.02 0 EPA 525.2 !.-l< 9/24/2 Atrazine ND mg/l 0,20 0: EPA 525.2 ;', 9/24/Rg Benzo (a) pyrene ND mg/l 0.041 0 EPA 525.2, 9/24/g0 9 ,-n Butachlor - ND mg/l 0.093 0 EPA 525.2 9/24/ 9 Di (2-ethylhexyl)adipate ND mg/l 0.56 400 EPA 525.2 9/2409 tZZ Di (2-ethylhexyl)phthalates ND mg/l 1.2 6.0 EPA 525.2 9/2409 03 Dieldrin ND mg/l 0.037 0 EPA 525.2 9/2v009 r Eridrin ND mg/l 0.020 0 EPA 525.2 9/24/2009 Heptachlor ND mg/l 0.037 0 EPA 525.2 9/24/2009 Heptachlor epoxide ND mg/l 0.041 0 EPA 525.2 9/24/2009 Hexachlorobenzene ND mg/i 0.093 0 EPA 525.2 9/24/2009 Hexachlorocyclopentadiene ND mg/l 0.20 0 EPA 525.2 9/24/2009 Lindane(BHC gamma isomer) ND mg/l 0.041 0 EPA 525.2 9/24/2009 Methoxychlor ND mg/l 0.20 0 EPA 525.2 9/24/2009 Metribuzin ND mg/l 0.20 0 EPA 525.2 9/24/2009 Propachlor ND mg/l 0.093 0 EPA 525.2 9/24/2009 Simazine ND mg/l 0.14 0 EPA 525.2 9/24/2009 Water samp�ple meets the recantmended Winits far drinking•water of all the above tested parameters Attached please find the laboratory certified parameter list. Approved By: ( Director) ND=None Detected RL = Reporting Limit MCL=Maximum Contaminant Level Superior Court House, PO. Box 427, Barnstable, MA 02630 Ph: 508-375-6605 ,pF It j CERTIFICATE OF ANALYSIS Page: 1 Report For: Barnstable County Health Laboratory 1 IV, Report Dated: 10/8/2009 Susan Phelan Order No.: G0954676 179 Plum St. West Barnstable, MA Laboratory ID#: 0954676-01 Description: Water-Drinking Water Sample#: Sampling Location: 179 Plum St.,West Barnstable,MA Collected: 9/16/2009 Collected by: Customer Received: 9/16/2009 EPA 524.2 - volatile Organics by GUMS ITEM RESULT UNITS RL MCL Method# Analyst Tested Note Dichlorodifluoromethane ND ug/L 0.50 EPA 524.2 yn 9/16/2009 Chloromethane ND ug/L 0.50 EPA 524.2 yn 9/16/2009 Vinyl chloride ND ug/L 0.50 2.0 EPA 524.2 yn 9/16/2009 Bromomethane ND ug/L 0.50 EPA 524.2 yn 9/16/2009 1,1,1,2-Tetrachloroethane ND ug/L 0.50 EPA 524.2 yn 9/16/2009 1,1,1-Trichloroethane ND ug/L 0.50 200 EPA 524.2 yn 9/16/2009 1,1,2,2-Tetrachloroethane ND ug/L 0.50 EPA 524.2 yn 9/16/2009 1,1,2-Trichloroetihane ND ug/L 0.50 5.0 EPA 524.2 yn 9/16/2009 1,1-Dichloroethane ND ug/L 0.50 -EPA 524.2 yn 9/16/2009 1,1-Dichloroethene ND ug/L 0.50 7.0 EPA 524.2 yn 9/16/2009 1,1-Dichloropropene ND ug/L 0.50 EPA 524.2 yn 9/16/2009 1,2,3-Trichlorobenzene ND ug/L 0.50 EPA 524.2 yn 9/16/2009 1,2,3-Trichloropropane ND ug/L 0.50 EPA 524.2 yn 9/16/2009 1,2,4-Trichlorobenzene ND ug/L 0.50 70 EPA 524.2 yn 9/16/2009 1,2,4-Trimethylbenzene ND ug/L 0.50 EPA 524.2 yn 9/16/2009 1,2-Dibromo-3-chloropropane ND ug/L 0.50 EPA 524.2 yn 9/16/2009 1,2-Dibromoethane(EDB) ND ug/L 0,50 EPA 524.2 yn 9/16/2009 1,2-Dichlorobenzene ND ug/L 0.50 600 EPA 524.2 yn 9/16/2009 1,2-Dichloroethane ND ug/L 0.50 5.0 EPA 524.2 yn 9/16/2009 1,2-Dichloropropane ND ug/L 0.50 EPA 524.2 yn 9/16/2009 1,3,5-Trimethylbenzene ND ug/L 0.50 EPA 524.2 yn 9/16/2009 1,3-Dichlorobenzene ND ug/L 0.50 EPA 524.2 yn 9/16/2009 1,3-Dichloropropane ND ug/L 0.50 EPA 524.2 yn 9/16/2009 1,4-Dichlorobenzene ND ug/L 0.50 5.0 EPA 524.2 yn 9/16/2009 2,2-Dichloropropane ND ug/L 0.50 EPA 524.2 yn 9/16/2009 2-Chlorotoluene ND ug/L 0.50 EPA 524.2 yn 9/16/2009 4-Chlorotoluene ND ug/L 0.50 EPA 524.2 yn 9/16/2009 Benzene ND ug/L 0.50 5.0 EPA 524.2 yn 9/16/2009 Bromobenzene ND ug/L 0.50 EPA 524.2 yn 9/16/2009 Bromochloromethane ND ug/L 0.50 EPA 524.2 yn 9/16/2009 Bromodichloromethane ND ug/L 0.50 EPA 524.2 yn 9/16/2009 Bromofortn ND ug/L 0.50 EPA 524.2 yn 9/16/2009 Carbon tetrachloride ND ug/L 0.50 5.0 EPA 524.2 yn 9/16/2009 ND=None Detected RL = Reporting Limit MCL=Maximum Contaminant Level Superior Court House, PO. Box 427, Barnstable, MA 02630 Ph: 508-375-6605 CERTIFICATE OF ANALYSIS Page: 2 of Kam• Report For: Barnstable County Health Laboratory 9srn [us` Report Dated: 10/8/2009 Susan Phelan Order No.: G0954676 179 Plum St. West Barnstable, MA Laboratory ID#: 0954676-0.1 Description: Water-Drinking Water Sample N: Sampling Location: 179 Plum St.,West Barnstable,MA Collected: 9/16/2009 Collected by: Customer Received: 9/16/2009 EPA 524.2 - Volatile Organics by GC/MS ITEM RESULT UNITS RL MCL Method# Analyst Tested Note Chlorobenzene ND ug/L 0.50 100 EPA 524.2 yn 9/16/2009 Chloroethane ND ug/L 0.50 EPA 524.2 yn 9/16/2009 Chloroforni 1,4 ug/L 0.50 80 EPA 524.2 yn 9/16/2009 (;Is-1,2-Dlchloroeflhene. ND." UgL 0.50 70 EPA 524.2 yn 9/16,'2009 cis-1,3-Dichloropropene ND ug/L 0.50 EPA 524.2 yn 9/16/2009 Dibromochloromethane ND ug/L 0.50 EPA 524.2 yn 9/16/2009 Dibromomethane ND ug/L 0.50 EPA 524.2 yn 9/16/2009 Ethylbenzene ND ug/L 0.50 700 EPA 524.2 yn 9/16/2009 Hexachlorobutad ene ND ug/L 0.50 EPA 524.2 yn 9/16/2009 1sopropyIbenzene ND ug/L 0.50 EPA 524.2 yn 9/16/2009 Methylene chloride ND ug/L 0.50 5.0 EPA 524.2 yn 9/16/2009 Methyl-tert-butyl ether ND ug/L 0.50 EPA 524.2 yn 9/16/2009 Naphthalene ND ug/L 0.50 EPA 524.2 yn 9/16/2009 n-Butylbenzene ND ug/L 0.50 EPA 524.2 yn 9/16/2009 n-Propylbenzene ND ug/L 0.50 EPA 524.2 yn 9/16/2009 p-Isopropyltoluene ND ug/L 0.50 EPA 524.2 yn 9/16/2009 sec-Butylbenzene ND ug/L 0.50 EPA 524.2 yn 9/16/2009 Styrene ND ug/L 0.50 100 EPA 524.2 yn 9/16/2009 tert-Butyl benzene ND ug/L 0.50 EPA 524.2 yn 9/16/2009 Tetrachloroethene ND ug/L 0.50 5.0 EPA 524.2 yn 9/16/2009 Toluene ND ug/L 0.50 1000 EPA 524.2 yn 9/16/2009 Total xyl.enes ND ug/L 0.50 10000 EPA 524.2 yn 9/16!2009 trans-l,2-Dichloroethene ND ug/L 0.50 100 EPA 524.2 yn 9/16/2009 trans-1,3-Dichloropropene ND ug/L 0.50 EPA 524.2 yn 9/16/2009 Trichloroethene ND ug/L 0.50 5.0 EPA 524.2 yn 9/16/2009 Trichlorofluoromethane ND ug/L 0.50 EPA 524.2 yn 9/16/2009 Water sample meets the recommended limits for drinking water of all the above tested parameters. t Attached please find the laboratory certified parameter list. Approved B f� -�. PP Y' --- (La ircctor)i ND=None Detected RL = Reporting Limit MCL=Maximum Contaminant Level Superior Court House, PO.Box 427, Barnstable, MA 02630 Ph: 508-37576605 August 15, 2002 Outback Engineering 106 West Grove Street Middleboro, MA 02346 (508) 946-9231 Town of Barnstable Health Dept. 200 Main Street Hyannis, MA 02601 Re: 138 Plum Street Septic System Inspection To Whom It May Concern: Please be aware that Outback Engineering has conducted the necessary inspections for the subject property. The newly installed Title V system was found to be in compliance with the approved plan. Very truly yours, $ames A. Pavlik, P.E. :ti t No.....�y_ .....3 Fps................... f� rTHE COMMONWEALTH OF MASSACHUSETTS eOA ® OF, HEALTH _ .0-trap................OF........B..........0!`T 6 ........................................ ApplirFation for 11ispos ai vrk,' Tonotrnrtion ramit Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal System at .... ........... - - (� L ation-Address or Lot No. ner Address Installer Address dType of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms....__3....•...........................Expansion Attic (4b Garbage Grinder (Jp) Other—Type e of Building _p,, yp g _.._. eA_________________ No. of persons............................ Showers ( ) — Cafeteria ( ) f-4 Other fixtures -------- --•----•-------------•- . W Design Flow...................1_1.®................gallons per person per day. Total daily flow__.__........ ..............._ lons. WSeptic Tank—Liquid capacit ./O.Q.4.gallons Length....)o...... Width........ ...__ Diameter__ �R______ Depth.. ........ x Disposal Trench—No.-----ki. ...... Width........0 /A.... Total Length___.....-1i..)��__ Total leaching area.. ...........sq. ft. ._� Seepage Pit No.-A... iameter._4!-___-__---__ Depth below inlet.....�2............ Total leaching area......AA...sq. ft. Z Other Distribution box (..... Dosing tank ( ) '4 Percolation Test Results Performed by...__..___.E�Ll. G1 FFO ® �I �� a Date Test Pit No. 1.....WA...minutes per inch Depth of Test Pit- __ i...._. Depth to ground water►�_T:�+`�S T�l3 f=, Test Pit No. 2.......�3_.......minutes per inch Depth of Test Pit.._....:E�.....-. Depth to ground watei*AT!e4 •---•-----------------------•--••-_..r..................._-•••-•............................................---•--•---...................--•-••...._.....-- O Description of Soil.....-M-51-111. i---•-� I jonn1 t.-Suo �-� i._'.�_?-._m Dium._16 ......... ; + , sin.. '�►tS B �,� ---'--RC@----o----)-•- --mEoT---FINE SAD--wi-iA-TR-ace--- f�nj.......... U Nature of Repairs or Alterations—Answer when applicable.............l..44A........................................... ............................ ----------•----------------•-------------------------------------------------------..........-•--------•------------------------------------------------------------------------------•••-••-....-•••-- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sani a y Code—T undersigned further agree t to place the system in operation until a Certificate of Compliance ha en issued b e b d of health. Q Signed ......••-•-- O �G Da� ApplicationApproved By----------••--•----••-...•----•--•...•••---•-•••-••.................•...............•--••-.•--•-- ........................................ Date Application Disapproved'f orrtthe following reasons:.............................................................................................................. -- -----------------------------•-•----•----•------...............-----•-•-------------------------------------------.--- Date Permit No.... ..�- ..... Issued.... Date THE FOLLOWING IS/ARE THE BEST IMAGES FROM POOR QUALITY ORIGINAL (S) M � L DATA N Y THE COMVONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Appliration for Diopoottl Works Tonstrnrtion ramit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual •Sewage Disposal System at: s`� ...-•----•. -- --•---------------•----•---- -------------------------.....--------..............-- ...... .� .....--- -•--- Location-Address Lot N or o. S.J ........ - - ......... :_..._ C1 .... :._.._..... /...............................-.............. .. 4� Owner Address �C,rc�a�d� ---- --------------- -----------•--••-----•-- -----•------ --...---...------•------------------ Address-- Type of Building Size Lot..��,__/Q........Sq. feet a Dwelling—No. of Bedrooms............................................Expansion Attic ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) � Other fixtures -------------------------------------------------------------••••-•------•••--•---•.....-•--•--•-•----•--...---•----••••-----•-•••••-----••---....... W Design Flow.............%lQ.........................gallons per person er day. Total daily flow__-_-_dl�®•••---------........_....__gallons. WSeptic Tank—Liquid capacit A. -.gallons Length__/�_...... Width.. ."�.._ Diameter__���_... Depth....4 x Disposal Trench—No........ ........ Width._N.,�q..__._... Total Length..Alt -`..... Total leaching area...�`_-------sq. ft. +� Seepage, Diameter...... ........... Depth below inlet................. Total leaching area......s;_��.�_..q. ft. See e Pit No....__..1 1 Z Other Di'sti-ibution box'(✓)' Dosing tank � ) Percolation Test Results Performed by......1..5 C��O� Date...._(;i ................ 04 Test Pit No. 1___--���._minutes per inch Depth o Test P Depth to ground water_A?KK� D Gi, Test Pit No. 2...j.........minutes per inch Depth of Test Pit.......?Z....... Depth to ground water.,P_!T 9V' • . . ------•------•-------......................................................... �O�I Description of Soil.....7. .......... ..........Q1 _G.a .' '.... .dvl3Sal L ��-/-/�" A-74WIUp6`°1..�..AML-1--�`M_ _6 VAn-- `-----1 _.__.P --- ?`-•----------------------------------------------.---1--=---� ,....."-_�l v_kN---.r7!.Tf�! ................. IU Nature of Repairs or Alterations—Answer when applicable_________ ____........................_____________________________________________ ___ces_______ --•- -•••••-••••••-•••-•--•-•--.....••••••-••----••-•-•---••-•------••••••--•......................•••. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITI2 5 of the State Sanitar Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance ha b n issued b e d of health. Signed... ... ...... . ... .... .........•. --•--. ............... Date ApplicationApproved By...........................••• -----•••--•.....••..................•••••......-- Date Application Disapproved for the following reasons---------------•----------------------------------•----•-------•-----------------•-----------------.........-•--- ---------•--......----•-.......•-------------------------------•-•--....--------•-•-------•---------,..----------....-------------------------- ------------------- Date PermitNo..-•_-•7 cf ---- r.3---------------------------• Issued.................. �......-----•------------....... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .. ...........OF........... ,. .... f.,, . Trrtifiratr of Tompliatta THIS IS TO✓.EA�?,T-IFY;! at tpgjpIdividual Sewage Disposal System constructed ( ) or Repaired ( ) by.......................................................----......__........::-----•-•--•-------......-•-••fir ---- ---- .---- --- ----------------------------•--------•--- /. /,74 L-"r r T' /-J` nga('�er fia"•,/ '' /<-S i .. .3=>r'`� at...................................................................................................... has been installed in accordance with the provisions of TITS - y of.The State Sanitary Code)as scrjbeck in the application for Disposal Works„Construction Permit'No........................................ .. dated----------.---------------...................... THE ISSUANCE OF THIS CERTIFICATE SHALL-•NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE............. - 'r .�� j .. �� Inspector. _' wr• ' , 7 f3 1)0 i ec..THE COMMONWEALTH OFJM�A�SSACHUSETTS BOARD OF HEALTH /i�'�rc- ...OFti�'•.'a•rc! t...... No..............? ...:: Y _ FEE........................ :-} Permission is hereby granted....................•=-_.....e;.:...*....-----.--•••----•----• "!=7,e7 to' Construct ( ) or Repair ( ) an Individual Sewage Disposal System r f, at No "!a ` .............................................................-.........................................-----------•------ -------------------•••••................... Street as shown on the application for Disposal Works_,_Construction Permit No.- -_-__--_.__ Dated.....'............. ....... ............ ..............I......--•--...--•---•-- -• ................ r '. Board of Health DATE•---- . ..............................•.•..•........i........_......._....... n"+' "! 1255 A. M. SULKIN, INC., BOSTON S -- - -•' - 1 ` 1 d r' Massachusetts Water Resources Commission/Division of Water Resources WATER WELL COMPLETION REPORT I V�WE��7CATIOM Address- _ City/Town WLZS�/ AAAt I► @ . u468 G.S.Quadrangle Map Grid Logatiqn Owne a O Address Sy±:St!, it Q#VSLO WELL USE CONSOLIDATED WELL Domestic Public ❑ Industrial Type of er-bearing Rock Other Water-bearing es METHOD DRILLED 1) From To Rotary(type) CableX 2) From To Other 3) From T 4) From-To CASING t/ Depth to Bedrock Length Fs 9 . Dia eter 'Type S 7 La UNCONSOLIDATED WELL STATIC WATER LE EL Water-bearing Materials . Feet below land surfa e4g,3 Sand: fine❑ medium coarse Dati.measured 0 7 Gravel: fineC3 medium Q. coarse Screen: GRAVEL PACK WEL Yes ❑ No SIot# OIa length 7 froms to� Split Screen(or 2nd screen/ WATER QUALITY TESTS MADE Slot# length from to Chemical Biological Depth To Bedrock PUMP TEST / Drawdown feet aft/er pumping daysLhours at GPM. How measured_ 7A Recovery feet after urs. \LOG of FORMATIONS z� COMM€NT$: (Qn w l or ter) a terials From Topea ,r„ttq V 0 (04 r!' �o R I L `, 51 Firm t?t/ t S4 G O o a Address 6 6 OAd 6 0 JANLW City • A'tA! MA 6 A 16 Registration No. c- Operator's gnature ease print irm y Log Number:- 3996 Bottle # 116 Date• � �'` OF BA4 �� sh BARNSTABLE COUNTY HEALTH DEPARTMENT a SUPERIOR COURT HOUSE V BARNSTABLE, MASSACHUSETTS 02630 r A1g80 DRINKING WATER•LABORATORY ANALYSIS PHONE: 362-2511 EXT. 331 Client: 2h: llip fiord Collector: R. R. Clough Mailing Address: ob 3t-wey bTxaet Affiliation: Cl.owth & Cahoon rrdolph, p� UZ Time & Date of Collection: Stoo R1 ' 8..6-04 Telephone: Type of Supply: r,011 trstor Sample Location: Plum Str-cot Well Depth: 90{ 11. Bar=tablo, IIEL Date of Analysis: A.i,^'= 6, 1914 PARAMETER SAMPLE RESULT RECOMMENDED LIMITS Total Coliform Bacteria/100 ml C' 0 H 6.1 Conductivity (micromhos/cm) 68' 500.0 Iron ( m) C`4 0.3 Nitrate-Nitro en ( m) <.04 10.0 Sodium ( m) - 20.0 I . Water sample meets the recommended limits for drinking of all above tested parameters. II. Based only on results of the parameters tested for this sample, the water is suitable for drinking but may present the problems checked below: A. Water sample has higher than average levels of Nitrate. Future monitoring is recommended (2-3 times per year) to establish any upward trends. B. The low pH of the water may shorten the useful life of the house's plumbing. C. X Water may present aesthetic problems (taste, odor, staining) due to bi&sh anon D. Water sample has high levels of sodium. Persons on low sodium diets should consult their doctor. III. Due to one or more of the reasons checked below, this water sample is unfit for human consumption: A. High Bacteria B. High Nitrates REMARKS: CC* instable Board of Roalth CC: Clough & Cahoon 7/17/64 Laboratory'Director ` 'Explanation of Test Results Total Coliform Bacteria Coliform bacteria are an indicator of the sanitary quality of a water supply. Water supplies may become contaminated from malfunctioning septic systems,cesspools and surface runoff. A total coliform count of zero indicates that your water supply is safe and approved for human consumption. A total coliform count of greater than zero is most often the result of accidental contamination of the sample bottle through improper sampling methods. For this reason, it would be advisable to retest any well water that is not approved. pH pH is the measure of acidity or alkalinity of the water.On the pH scale, the number 7 is neutral, less than 7 is acidic and more than 7 is alkaline. The pH of water on Cape Cod tends to be acidic in the range of 5.0 to 6.5 Conductivity Conductivity is a measure of the dissolved salts in solution. Amounts in excess of 500 micromhos 1cm are generally considered unacceptable and may have a laxative effect upon users. Iron The presence of iron in water in concentration of .3 ppm or greater may: give the water a bittersweet astringent taste, cause an unpleasant odor, often gives the water a brownish color and cause staining of laundry and porcelain. The average concentration of iron in Cape Cod's water is .2- .6 ppm. Although the presence of iron in water may cause the problems listed above, it is not considered deleterious to health. Iron may be removed by use of an iron removal system. Nitrate-nitrogen The Massachusetts Drinking Water Regulations have set a maximum contaminant level for nitrates at 10 ppm. Excessive concentrations may cause methemoglobinemia (an infant disease) and have been suggested to form potentially carcinogenic nitrosamines. Contamination sources include fertilizers, cesspools and industrial wastes. Copper Due to the acidic nature of the water on Cape Cod, copper tends to leach from pipes. This normally does not present a health hazard; however, concentrations in excess of 1.0 ppm may cause a metallic taste and/or a bluish green stain on porcelain fixtures. Sodium A concentration of sodium over 20 ppm is only of concern to people who are on a low sodium diet. If the water supply has more than 20 ppm sodium, it is up to the people who are on such a diet to find another source of drinking water or contact their doctor to determine if consuming the water is advisable. Concentrations exceeding 50 ppm indicate that there may be ocean water or road salt runoff water vetting into the well. 2 G F T. M I u, I JoTF I F E 17-H�.( T+--I E Sa Pr I G 7-t-,�k o k LEACN1wlF3 PIT A-RJ--- MORE T>-IA►J I2" L3�Ir�W R,4-pE , A 2 4 .p I A NIGF�Q r— rO cTE GG�R i `-- SHALL f 8Ro��6HT TO GPADa ( D2Ivr=wAYS cn=., VaTa= / 4 RiG P I Dl=- Ee 1 R8 A u ExTRA H F-AW D-n--,e CAST I"j c,=,vEt / M I L1. PITc 1•-�� EL.- I oo.S /�caERs P�EQ FT. ) 1 Mlr..l. A / \ C.RAD=- coV�R clt 1.1-sA/�D 4"cAsT /. 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I ,, . �J,�, , . .A"6. � 4 , � . , .. . !�� 0 i - t"' - �� r I .- ?, I I, . .� � .. q * ,, I- * ,i �,�" , ,�, , ,. li,.1. .1 't�!'..;��g-�­ -4��- " , ,-�� . =,7, �, -14 , , * 6 6� . '�'�i' '.( li . - I� 4�,,. "�,I I , . • t, , , . -- - ,- . . I 11 ",,, %` I ` ,. , , .t . -,' A , � 11'.I ♦ � ., " .� 6 .1 * i '. _ � �� �,, �'Wl �� '. .,',,,-6 � , N � I .k ), .1.I I. , .� , . 6 � , '' �,) . .,. I , I : �'r.. I . �. ,'k� , . .r� , � , I Al ,�,�', 'VI'� ­ . . k I I '.',�, "�"I ,� ,. r . , T .� .A,. - -: ", -R t, � .- ., ��� . ,.!", �; ". _� 4,:-� -� - .. I .k'!i�-j ,-�,� I ,�, � , - , ,I . , .1 - . . � I -- , ­ .: � FEE ` TOWN OF EARNSTABLE - ` OFFICE OF eAsasrrai BOARD OF HEALTH ruIL ��pp a639. `e� 367 MAIN STREET lEo�A�k HYANNIS, MASS. 02601 VARIANCE REQUEST FORM All variance requests must be submitted five (S) days prior to the sched led Board of Health meeting. NAME OF APPLICANT PN 1 LL I P Fc) -Z TELEPHONE NO. 963- 1849 ADDRESS OF APPLICANT (o(o S'n'4CE-( S'TQI<ET K �-►DoLP� _ ASS . O'L368 NAME OF OWNER OF PROPERTY Pt+l LL iP FaP.b (ks A-L'�ovF- LOCATION OF REQUEST p-r PLUM ST Iac A/loca W . gA-R�T9°t-gL� ' VARIANCE FROM REGULATION (List regulation) 1501 c=,f= i=T WELL 5E7PT1G VARIANCE REQUESTED (Specific request) P6P, WELL TM, 06P. LeAcH iw6, PIT FEET (ALLOW 130 oFF5C-T) ; PROP wE•LL.. Tb P" PL-'SC-QvE Aler=A 35 Fe-C-T A LLc:,W 11 S of FSET ) REASON FOR VARIANCE (May attach letter if more space needed) Locus wELt_-/�SEPT�c�HSI= L0cAllalr5 DIGT'ATetb (1 ) LoT 6cuP16v(2.4T1oI.1 � LQ TaPo�s2ArOrF`-( �1•E. 13huK- DQoP_ "rd Poi.-ID _ C3) �I t cGuD. noa15 ^wb (4) AD.f Ac--W-r EX ISTn W C3 WELL- /sE�PT►c LocA-nc5w5 PLANS - Two copies of plan must be submitted clearly outlining variance requested. VARIANCE APPROVED . NOT APPROVED REASON FOR DISAPPROVAL 22downoiBarnstable Robert L. Chi lds, Chairman I�ISI.s�VLS Ann Jane Eshbaugh JUL 9 1984 H. F. Inge, M. D. BOARD OF HEALTH TOWN OF BARNSTABLE 20 FT. nA 11.1• t lo'r� I F E ITH a{z TN E SE PT t c 7 �u IL ok (f-=Ae: ►4IW6 P►T orRB MoR1= Tt-li+-j 12" ez!IAW I C P71 M 1w RA- 0 , A 24~b I P Mc'"�2 c,= r-D>=Z E cx=va Q- / 1-- 4 R/C PIPE _ s+-TALL � f3oR Y I-4T -To GR-AD� ( DpI J�WAVS ccl_lc Rt=-r� I QEcx-jI 2- Au M—,C R A H EASY Dc1 CA-Sr I Rau covE=Z EL • Ioo.S �co,iERs � � M Imo. PITCI-•-4 PE Q FT. ) 1 cal_lc QErm; C1EEAtJ-5A/.►D / ��� \ i'— USED t►-.I I�AGKFi IQJID LEVEL.-� g,�± L : ✓ - 2"LA�IE�oF �e~- 3/8 I Rl=>W PIPE i 1 000 -klAAL M-l' wA51-FED Scout= PITc+-I G-rAL. o • • o ( p o 0 0 0 0 1 A Pff:P- FTr �PTIG TANG FIST. • Q^ ° p p o 0 0 l 13oK ° O 1 0 8 0 0 0 l 1 1 • EFFECT'I"/a ' o • 3�4" - lb 1 ' i�Pr►-I ' ' � WP6t•+ED S-ra-1C ° • 1 1 p e o o p p 1 P^E.9-A 5r `SESPrr=�E II-1\/EQT EL�/ATIo►JS . ° 1 I o o a o o ► I o � PlT o� E�cJF�L� `/ �, I IJ�7EQT AT BLALDtI-leb �1-1•S FT. F'f: D/AM. a I �L = �. I,� (>J LET SEPTIC TA►-11L 9-7.3 FT• PIT cAPP•GIN 48G.-7 6/D - FT, DIAM. "I� C (gam TABu�ATIOt�� J oL.Tr LET 5E PT'I G TA ki K 9-7. 1 FT. I u LET D t5T-1 Px fT c=>" 1 )( 9 4-.9 FT. 5E�r I owl o F G Rau h D WATE lL duTt�T DIST(ZIB�1rtc+-1 Box 9(.. .-7 FT• - r_1ci We -la4 �resT T I INLET LEEA,* "ti . PIT 9 S•-7 PT. SSW AGE D ISPoS,Pr SYSTEM � = T4.Lo . I� I LEA c I•-•a I I�16 PIT DESI6L1 GRi7F-- r� �cAL>= : I/4" I ' o �IMEI.t�tol.l A 3 �-. D l M EI-ls i ol..t 5 4 FT. IJuM l r2 of Br=DQc tS 3 D 1 M>=t_t Slot_l C 4 FT.. GARBAC=I= DrsPcr--AL. vutT )-J--E I L LOCH TCDT^L Esc]M ATED FLOW 3 3a MAL' IC A-e so I L TEST 1.1= I 'Sc:,1 L TP=T W tiluM6E-P- of L--A--44l+.16 PI-5 I E L= I03. 1 tL " 104.•3 -ram aF SotL"1�5T ��9 St[>E LI=A,--HtLt6 PER- AIT 1�5.9 �• F`r. 1 ' LccAM a-�' LohM Sr 12ESuL-05 Q.�D f��( ELLlS �G 1 F-=-�c��-D Dc=,TTzoM I F A�.H I w6 POP-AT 153.9 �.�. FT. h(3� �ar�I� D�� A�o.� PA'i� Q t I o rR L LEAN-1 t I.16 f�Q�A 3'L9• g S� FT- IL M/u /I uc► 1 I ( RCnLFIaTlO 1-. QArTI✓ IJ (�5�vE L.�A--"I W6 AO-CA 5 .a Sq. �T P msT EflwM —�— G 4'p lr=k=I L "II -S 1-14 SAHO 1 -7 MED rc AuE SN�F VJITHTQACCS AuD W ITH EQJ t1A OF M4T F fati iL'A`es of DAVID wE'ST a G F G of m C. / -7-I,L MEDIuM IliULiN s>' wD ba FO��FR�p4� `�pf $'TE��40`! -9 .3 fL9 MVSK]-6E7 LA"e, T�R�/ILLE, MASS 4H� SURD 1 N I,lo GQo��1ID wRTEQ>=uc� DD -7 ❑ 6�ouuD �arArEQ (2 EL �t�ur : F�� pf�Tl= 84 J. Rl1 a4 55 5r4�'T 'L of 2 BENCH MARK: TOP OF FND. ELE, (SAS) SHALL BE MANHOLE COVERS TO EXTEND TO " 2S- LONG �WITHIN 6' OF FINISH GRADE IZ WIL?F. • h .-� - Zv Lo �4 . .z DEEP o r, u BAFFLE REQ'D 20 r _l03:5o Q se �.o Al (o3.3OX 1S► 2' PEASTONE TOPPING ..- co3.o5 (e2.2t D.B. 2 .03 � � ``' - �vaL t, row col:'93 - CAP ENDS GENERAL NOTES: TA-J< Pr S = 3�4" DOUBLE WASHED — ELEVATIONS SHOWN BASED ON U.S.G.S_ DATUM. EL=sq �3 s ONE ALL AROUND SYSTEM PIPE SHALL BE EITHER C.I. OR ID r SCHEDULE 40 P.V.C. — THE BOARD OF HEALTH SHALL BE NOTIFIED 20' MIN. :g I1' ' �}' PRIOR TO BACKFILLING OF SEPTIC SYSTEM. — SEPTIC SYSTEM STRUCTURAL COMPONENTS. SHALL BE CAPABLE LE OF 1, th WITHS A Cn 'T' �dNDI USE TvJO Z Sq0 � I�� S NG A SOIL TEST LOG PROPOSED SEPTIC SYSTEM _ C , H-10 LOADING, UNLESS SPECIFIED OTHERWISE PERC RATE=< 2 MIN/INCH NO SCALE (� h u,6;y 5 . 4 c.LC—j S S t� ALL SEPTIC SYSTEM UNDER DRNEWAYS SHALL S E1p ptoLkTGj) L'o mk- j p+ S-TO T4 C , COMPLY WITH A H-20 LOADING. DEPTH ELEV. 1o®-p — THE DESIGN AND COMPONENTS OF THE SEPTIC A LOAMY SAND I 3 Z SYSTEM SHALL BE IN COMPLIANCE WITH THE t� STATE OF MASSACHUSETTS SANITARY CODE 9 LOWY SAND lam �l( DESIGNII ; ENGINEER ► TITLE V. AND SHALL BE IN COMPLIANCE WITH 2�} - INSTALL! DN MUST SUF��RVISE THE LOCAL BOARD OF HEALTH RULES AND THE SYS AND CEFMF-Y- WR(�--9�!Sf t 1J(, O� . b.'► WAS INST Cl MEDIUM SAND torn �l2 hCCO.Rc,°;.�,,E TOP IN STWF REGULATIONS. PROPOSED �1t0.1 (SAS tS. tJOfLL� THE CONTRACTOR SHALL BE RESPONSIBLE FOR W tj1k IIJ I SO d� A►J X tSTtIJ(, ,�,i / _ LOCATION OF ALL UNDERGROUND UTILITIES AND 4.00 — Y - `� \ \ SHALL NO DIG - SAFE PRIOR TO Lk)ELL" ! - "' y, CONSTRUCTION. tZ0 U N A't" - _ { r .t,� — NO, GARBAGE GRINDER is . Igo �i)r v 5 DESIGN CRITERIA: GREATEP, -VISA `�{�' / P DESIGN FLOW LEGEND: 3 BEDROOMS AT 110 G.P.B. / DAY 330 G.P.D. EXISTING CONTOUR �ti .� REQUIRED SEPTIC TANK: WATER SERVICE W—W— i \. _-:lam ,- GAS SERVICE TEST HOLE r / -- -- - T G 0 0 -r- '. i� � ✓ `� SEPTIC TANK PROVIDED t!�1oNG� BENCH MARK. ._ DESIGN PERC RATE <2 MIN/INCH w Ay - - -1t" <; �•. V �V SIZE OF REQ D SAS AREA = 330 0.74 = 446 S.F. LL ��r5'F• SIDEWALL Z5� 5 +(2) _BOTTOM �2)�_ t2 ( 2 ) op( (S.F(Z- Z� $ SF SIZE OF LEACHING FACILITY PROVIDED: Nov S.F. + -7 o O S.F. = 44 5S.F. f CSAS� - t GPD I i EFFECTIVE DEPTH: _ _z - ` -�►'"� C� _( :-:i— EFFECTIVE LENGTH: . '�:' EFFECTIVE WIDTH: Zo Z ' l OUTBACK ENGINEERING a y�� 106 WEST GROVE STREET _ PAVLIK a MIDDLEBORO. MA 02346 ' CM co (508) 946-9231 - I) LA11- PROJECT: SEPTIC SYSTEM REPAIR Fol ` 13 IJ c.v�,R 1t ' NAl srxE AS SHOWN ?fZEE'T- owaM er , cab 40 ( � d 2 0 ' 11 LOT 03(0 owNE : PNI�Lrp SywIA Fo2D p.a. ilox 15e wtsT... �etJSTAb+-lr MA -7-7 �77 IOlt IToo!001 too? silly"IIIIIi :!jet IIIIIII'Ah�A N NITS,IIIIIIIAVE,IIIIVic Itic'A P--d— erL,IiA:IPA1 A IIlot got 1,II17 IIIII ,11171 IID _17 -J cn I OF II �J/,A II �ff', L I -T-H I17 F I1�7.. ......... II . ............ 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