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0161 PLUM STREET - Health
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Inspector InformationS/ # I till Q(p on the computer, use only the tab Christopher Maki key to move your Name of Inspector cursor-do not Cape Cod Septic Services use the return key. Company Name 350 Main Company rab Company Address W Yarmouth MA 02673 Citylrown State Zip Code B 508-775-2825 SI-14423 Telephone Number License Number 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 J AMVI 3/5/2020 Inspector's Sf§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 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. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of.Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -.Not for Voluntary Assessments 161 PLUM STREET Property Address ALAN DAVIS Owner Owner's Name information is required for every W BARNSTABLE MA 02668 2/28/2020 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 IS IN WORKING CONDITION 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.712 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection . Form Fio Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 161 PLUM STREET Property Address ALAN DAVIS Owner Owner's Name information is required for every W BARNSTABLE MA .02668 2/28/2020 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): El 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 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. 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 .c Commonwealth of Massachusetts l� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 161 PLUM STREET Property Address ALAN DAVIS Owner Owner's Name information is required for every W BARNSTABLE MA 02668 2/28/2020 page. City/Town 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 r Commonwealth of Massachusetts 1p Title 5 . Official Inspection Form �4 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 161 PLUM STREET Property Address ALAN DAVIS Owner Owner's Name information is required for every W BARNSTABLE MA 02668 2/28/2020 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 '/2 day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ Z. 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 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. 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 t5lnsp.doc•rev.7/26/2016 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 16 L Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 161 PLUM STREET Property Address ALAN DAVIS Owner Owner's Name information is required for every W BARNSTABLE MA 02668 2/28/2020 page. City/Town 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 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 sidns.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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18 Commonwealth of Massachusetts. 11P Title 5 Official Inspection form <i; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 161 PLUM STREET Property Address ALAN DAVIS Owner Owner's Name information is required for every W BARNSTABLE MA 02668 2/28/2020 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): 330 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 years usage (gpd)): WELL WATER Detail: 2015 PLAN SHOWS NO WELLS WITHIN 150' 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 Commonwealth of Massachusetts -IP Title 5 Official Inspection. Form It Subsurface Sewage Disposal System Form - Not for.Voluntary Assessments 161 PLUM STREET Property Address ALAN DAVIS Owner Owner's Name information is required for every W BARNSTABLE MA 02668 2/28/2020 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 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 below): 3. Pumping Records: Source of information: NA Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5ins .doc•rev.7/26/201 P 6 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 16 Commonwealth of Massachusetts -,A Title 5 Official Inspection Form Jh Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 161 PLUM STREET Property Address ALAN DAVIS Owner Owner's Name information is required for every W BARNSTABLE MA 02668 2/28/2020 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: TANK IS 1984, DISTRIBUTION BOX AND LEACH FROM 2015 PER ASBUILT Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): 17" Depth below grade: feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private.water supply well or suction line: +150' feet Comments (on condition of joints, venting, evidence of leakage, etc.): LINE CHECKED WITH SEWER CAMERA AND WAS FOUND TO BE CLEAN AND PROPERLY PITCHED. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts F Title 5 Official Inspection Form M1lo Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 161 PLUM STREET Property Address ALAN DAVIS Owner Owner's Name information is required for every W BARNSTABLE MA 02668 2/28/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.). 6. Septic Tank(locate on site plan): Depth below grade: 711feet 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: 1000 GALLONS Sludge depth: 211 Distance from top of sludge to bottom of outlet tee or baffle Scum thickness 1" Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? ESTIMATED Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 1000 GALLON TANK IN GOOD CONDITION. TEES IN PACE AND CLEAN. TANK AT NORMAL OPERATING LEVEL.COVERS 7" BELOW GRADE. t5insp.doc•rev.7/26/2016 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 16 L c Commonwealth of Massachusetts ,� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments w 161 PLUM STREET Property Address ALAN DAVIS Owner Owner's Name information is required for every W BARNSTABLE MA 02668 2/28/2020 page. Cityrrown 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 El metal ❑ fiberglass El polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 Commonwealth of Massachusetts ,42P Title 5 Official Inspection Form Fla Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 161 PLUM STREET Property Address ALAN DAVIS Owner Owner's Name information is required for every W BARNSTABLE MA 02668 2/28/2020 page. Cityfrown 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.): "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 EVEN 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.): DISTRIBUTION BOX LEVEL AND WATERTIGHT t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts -- -- a Title 5 Official Inspection Form IQ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 161 PLUM STREET Property Address ALAN DAVIS Owner Owner's Name information is required for every W BARNSTABLE MA 02668 2/28/2020 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. 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: 2-600 GAL CHAMBERS ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system 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 l� Title 5 Official Inspection Form Voluntary Subsurface Sewage Disposal System Form - Not for Y Assessments 161 PLUM STREET Property Address ALAN DAVIS Owner Owner's Name information is required for every W BARNSTABLE MA 02668 2/28/2020 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.): 2-500 GALLON CHAMBERS FOUND IN OPERATING CONDITION WITH NO STAINING. COVER IS 4" BELOW GRADE 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.): t5lnsp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18 Commonwealth of Massachusetts is Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments L. o 161 PLUM STREET Property Address ALAN DAVIS Owner Owners Name information is W BARNSTABLE MA 02668 2/28/2020 required for every page. Cityrrown 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 Commonwealth of Massachusetts Title 5 Official Inspection Form �t Subsurface Sewage.Disposal System Form -Not for.Voluntary Assessments 161 PLUM STREET Property Address ALAN DAVIS Owner Owner's Name information is required for every W BARNSTABLE MA 02668 2/28/2020 page. Cityrrown 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 ® drawingAttached separately t5insp.doc-rev.7l26l2016 Title 5 Official Inspection Form:Subsurface sewage oisposat System•Page 16 of 1 a r •M"N Commonwealth of Massachusetts Title 5 Official .Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 161 PLUM STREET Property Address ALAN DAVIS Owner Owner's Name information is required for every W BARNSTABLE MA 02668 2/28/2020 page. Citylrown 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: 12+ 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: 2015 Date ❑ Observed site(abutting hole wi thin 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: 2015 PLAN SHOWS NO GROUNDWATER ENCOUNTERED IN TEST HOLE LOGS, TEST HOLE 132" DEEP 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 @ Tithe 5 Official Inspection Form i� Subsurface Sewage Disposal System Form Not for Voluntary Assessments 161 PLUM STREET Property Address ALAN IDAVIS Owner Owner's Name information is required ired for every W BARNSTABLE MA 02668 2/28/2020 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: Z A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 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 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 LAcK Lie /000 an A y �. TOWN OF BARNSTABLE LOCATION ( PLym 5 7 SEWAGE# 03 VILLAGE es ASSESSOR'S MAP&PARCEL INSTALLER'S NAME&PHONE NO. eti r[rh e r SEPTIC TANK CAPACITY /000 % n c LEACHING FACILITY. (type) - So a cz- c-,h c,,,n b size) k r 2 ems' NO. OF BEDROOMS 3 OWNER 41ori PERMIT DATE: 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 i A /boo f3 A 4 - 71 r No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 1 ZippliLat1on for Disposal �&pstrm Construction Permit Application for a Permit to Construct( ) Repair(l<Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 1(p( if r--A s Owner's Name,Address,and Tel.No. A�OkAl O AA S Assessor's Map/ParceLN �jp�'�►5,t_% A 10tI PL Vm. 3� L,J, i/A 0VS1';b6L Installer's Name, dress,and 1.No. Designer's Name,Address,and Tel.No. (_[ A 00 oaf 201 P�r^P.wS r MA —7 3 Type of uil g: Dwelling No.of Bedrooms 3 Lot Size (® ?Z I sq.ft. Garbage Grinder( ) Other Type of Building l2 f S No.of Persons Z Showers( ) Cafeteria( ) Other Fixtures p� Design Flow(min.required) gpd Design flow provided 3 1 1 gpd Plan Date Number of sheets ( Revision Date Title &o po S C S-°.vJ&V 'Q 1S e&sA L 5*i1 S�pN� Size of Septic Tank 11000 q o01 Type of S.A.S. pKPICp . G(tAvn l Description of Soil 1/1/1 Q,[� Jsa'Ajt Zf "Wk r A.0 IAG vw J�rn Y'A toe,VLa4 $Gf O tt t„MIf cA CoG✓SC �A Nature of Repairs or Alterations(Answe when applicable) I"s+a (J *D —150y, a4 I1MU r[VC. Lly^.4 6 I o v c/ io wb4z< Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued^s Board of 1 h. ig4e, Date &- 2 Application Approved by Date Application Disapproved by Date for the following reasons IF Permit No. Date Issued No. Fee 'THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: 1 Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 01pplitatlon for Miopp8al 6pstem Construction Permit Application for a Permit to Construct(. ) Repair(Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. ' 10 ( Pt V r✓1 511 - Owner's Name,Address,and Tel.No. A N p A-A S Assessor'sMap/Parcel ' < �n1S�f�b�.t �q1 OW-,-,I gF' W' (�ArrvS}p�tti Installer's Name,Address,and el.No. Designer's Name,Address,and Tel.No. L l VI A /'14k S 100 (1Or 201 /tw5�> fi Type of uil g: F Dwelling. No.of Bedrooms 3 Lot Size 3( -1 Z 1 sq.ft. Garbage Grinder( ) Other Type of Building ( P S No.of Persons Z Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) :3?, gpd Design flow provided gpd Plan Date Number of sheets J Revision Date Title tZr•r n S 1 s� i_k,�u 7 l.S A2SA L 3`,,�s Size of Septic Tank ! (IgC) C. a Type of S.A.S. Description of Soil PA -P,� 5r r Q, 0f: w 11)"1 ,, _n (,nr-,. ^4 S 12"0 Nature of Repairs or Alterations(Answer when applicable) f n,t- ( F�,�Y r.N/ i 1.w(j rt lPC +• 1 Lti n v� rw 6'.0) C, A Date last inspected Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued b s H i Board of �g_ d ;0 0 Date (Y 2 Application Approved by -Date Application Disapproved by I Date for the following reasons , 1 .-� Permit Now Date Issued ------------ -< -'------- --,--------------- HE f� �' COMMONWEALTH OF MASSACHUSETTS (j 'B INSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired Upgraded( ) Abandoned( )by bIw at has been constructed in accordance,, _ with the provisions of Title 5 and-the-for Disposal System Construction Permit No. ed Installer Designer #bedrooms 3 Approved design flow gpd The issuance of this p ' shall not be construed as a guarantee that the system will o as designed. Date -7� Inspector iC11, v -- -------------- ---- -- -------------------------- ------- ------------ -------------------------------------- No. l Fee COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Misposal *pstem onstrnttlon Permit Permission is hereby granted to Construct( ) Repair( Upgrade( ) Abandon( ) System located at (o Vh 5 and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construe 'o Zt/bicompleted within three years of the date of this permit. Date Approved by i TRANS. NO.: CITY/TOWN: APPLICANT: ADDRESS: 1 lam S�. �r�S bl�• DESIGN FLOW: gpd REVIEWED BY: DATE: N/A OK NO Legal boundaries denoted [310 CMR 15.220(4)(a Street, Lot,tax parcel number and lot number noted on plan [310 CMR 15.220(4)(u)] Locus Provided [310 CMR 15.2204(t)] Plan proper scale? (1"=40' for plot plans, 1"=20' or fewer for / components) 310 CMR 15.220(4)] V Easements shown [310 CMR 15.220(4)(b)] System located totally on lot served [310 CMR 15.405(1)(a) for upgrades]- if not, a variance is required [310 CMR 15.412(4)] Location of impervious surfaces(driveways,parking areas etc.) [310 CMR 15.220(4)(d)] Location all buildings existing and proposed 310 CMR / 15.220(4)(c)] y Location and dimensions of system components and reserve / areas. 310 CMR 15.220(4)(e)] V System Calculations 310 CMR 15.220(4)(f)] daily flow septic tank capacity (required andprovided) soil absorption system(required andprovided) whether system designed for garbage grindei North arrow [310 CMR 15.220(4)(g)] Existing and ro osed contours [310 CMR 15.220(4)(g) Location and log of deep observation holes (existing grade el. on each test) [310 CMR 15.220(4)(h)] Names of soil evaluator and BOH representative [310 CMR / 15.220(4)(h) and i) ✓ Location and date of percolation tests (performed at proper elevation?) [310 CMR 15.220(4)(i)] Percolation test results match loading rate?'[310 CMR 15.242 Certification statement by Soil Evaluator 310 CMR 15.220(4)0)] Observed and Adjusted groundwater(method for adjustment given or indicated) [310 CMR 15.103(3) and 310 CMR ,l 15.220(4)(n)] Address Sheet 1 of 7 � I N/A OK NO Location of every water supply,public and private, [310 CMR 15.220(4)(k)] within 400 feet of the proposed system location in the case of surface water supplies and gravel packed public water supply within 250 feet of the proposed system location in the case within 150 feet of the proposed system location in the case / of private water supply wells • Location of all surface waters and wetlands located up to 100 ft. beyond setbacks listed in 310 CMR 15.211 and any catch basins J located within 50 ft. [310 CMR 15.220(4)(1)] Water lines and other subsurface utilities located [310 CMR / 15.220(4)(m)] if water line cross see 310 CMR 15.211 1 1 ✓ Profile of system showing invert elevations of all system components and the bottom of the SAS 310 CMR 15.220(4)(o)] Stamp of designer 310 CMR 15.220 1 and 310 CMR 15.220(2)] Stamp of Registered Land Surveyor(required if construction / activities within 5 ft. of lot line) [310 CMR 15.220(3)] Test Holes adequate (two in each of the primary and reserve unless trenches as permitted in 310 CMR 15.102(2)or as approved for an upgrade under LUA at 310 CMR 15.405(1)(k)] Test hole adequate to demonstrate four feet of suitable material? [310 CMR 15.103(4)] Test Holes adequate to confirm adequate groundwater separation? / 310 CMR 15.103(3)] ✓ Benchmark within 50-75' of system 310 CMR 15.220(4)(g)] Materials specifications noted? [various sections of 310 CMR 15.000] System components not> 36" deep(unless Local Upgrade Approval or LUA requested) 310 CMR 15.405 1 b Address �,a . m 5�. Sheet 2 of 7 N/A OK NO Size OK? 310 CMR 15.223 1 Inlet tee located ten inches below flow line 310 CMR 15.227(6)] Outlet tee 14" or 14" +5" per foot for increase ft depth [310 CMR / 15.227(6)] ✓ Outlet tee with gas baffle or approved filter [310 CMR 15.227(4)] Note regarding installation on stable compacted base [310 CMR 15.228(1)] J Separation between inlet and outlet tees(no less than liquid depth) [310 CMR 15.227(2)] ✓ Inlet/Outlet elevations at least 12" above high groundwater (except as described 310 CMR 15.227(5)) or permitted for uparades under LUA 310 CMR 15.445 1 k Minimum cover 9" (Tanks buried more than 9" must have risers on all openings and on the d-box) [310 CMR 15.2228(1) and 310 CMR 15.232 3 Three access covers(inlet and outlet must be 20" or greater) middle access at least 8" (by 7/07) [310 CMR 15.228(2)] Access to within 6 " of grade - one port for systems<I 000gpd, / two for systems>1000 gpd [310 CMR 15,228(2)] .......... All at-grade covers secured to unauthorized access? [310 CMR 15.228(2)] > 10 ft from building foundation [310 CMR 15.211(1)] Buoyancy calculation Required/Done 310 CMR 15.221 8 H-20 Where appropriate? [310 CMR 15.226(3)] Setbacks from resources 310 CMR 15.211 p Required when other than single-family dwelling or flow>1000 d 310 CMR 15.223 1 b First compartment 200% daily flow; Second compartment 100% daily flow[310 CMR 15.224(2) and (3)] "U" pipe through or over baffle, outlet of each compartment with gas baffle or approved filter [310 CMR 15.224(4)] Address o o m 5�, Sheet 3 of 7 • 1 I N/A OK NO VItIalER� RrANHOTIE {Y Located at least ten feet from any water line? [310 CMR / 15.222(2)] ✓ Disposal piping at least 18" below water line (when water and sewer cross, see 310 CMR 15.211(1)[1]) Cleanouts required/provided? [310 CMR 15.222(8)] Thrust blocks specified in force mains? 310 CMR 15.221(6)(c)] Slope of sewer line not less than 0.01 (1/8"/ft) 0.02 preferable / [310 CMR 15.222(6)] Proper pitch on all runs? (.005 within gravity-distributed trenches / and beds) [310 CMR 15.251 9 and 310 CMR 15.252(2)(c)] Siphon roblem/ leachfield below pump chamber Endca s or vent manifoldspecified? Size and orientation of discharge holes specified? (not smaller than 3/8" not larger than 5/8") [310 CMR 15.251(8) and 310 J CMR 15.252(2)(h)] Materials specified (310 CMR 15.251(5) specifies various pipe types allowed) Stable compacted base[310 CMR 15.221(2) and 310 CMR 15.232(2)(a)] Splash plate or baffle tee required on inlet/'provided? (when pressure sewer to d-box or steep pitch of gravity sewer) [310 CMR 15.323(3)(a)] Riser if deeper than 9" 310 CMR 15.232 3 Inside minimum dimension 12" 310 CMR 15.232(2)(b)] Minimum sum 6" 310 CMR I5.232(3)(e)] Watertight cover if<2000gpd); waterproof manhole if>2000gpd / [310 CMR 15.232(3)(d)] ✓ Capacity (emergency storage above working=design flow)? [310 CMR 231(2 Proper setbacks [310 CMR 15.211 same as septic tanks Watertight 20-in minium access manhole at least 20" MUST BE / TO GRADE [310 CMR 15.231(5)] '/ Service components accessible (not too deep with piping, disconnects accessible Alarm floats- alarm on circuit separate from pumps specified? Exceeds two units must have two.pumps operating in lead-lag mode. 310 CMR 15.231(6) and 8 Stable Compacted Base [310 CMR.15.221(2)] fBuoyancy calculations needed ? Provided? [310 CMR 15.221(8)] Address Q'U M Sheet 4 of 7 N/A OK NO �OII��ABSORP1a.IONS1'STEMS� SAS GG�i� � yf ,, � ,� , ;; Calculations correct? 4 feet of naturally occurring material demonstrated? [310 CMR / 15.240(l)] ✓ Required separation togroundwater? [310 CMR 15.212)] Aggregate specified as double washed [310 CMR 15.247(2)] System Venting required/provided? (system under driveway or / >36" deep) [310 CMR 15.2411 Inspection ports specified and within 3"final grade? [310 CMR 15.240(13)] Breakout requirements met? (No violation of breakout elevation within 15 ft of SAS unless barrier) [310 CMR 15.211(1)[4] and J Guidance Document G' m LERIS>l}ITL CHMBERSI`©rC1�IR1253 '` 5NOW Chambers and Gal. in trench configuration supplied with inlet / every 20 ft. 310 CMR 15.253(6)] Each structure with one inspection manhole (if>2000 gpd must / be to grade) [310 CMR 15.253(2)] Aggregate I' minimum-4' maximum. [310 CMR 15.253(1)(b)] 2' sidewall credit maximum [310 CMR 15.253(1)(a)] In bed configuration, inlet every 40 s . ft. [310 CMR 15.253(6 a Width 2' minimum 3' maximum [310 CMR 15.251(1)(b)] 100 feet- maximum length 310 CMR 15.251 1 a ] Minimum separation 2x effective depth or width whichever ✓ greater 3x if reserve between trenches 310 CMR 251(1)(d Situated along contours 310 CMR 15.251(2)] Breakout OK? 310 CMR 15,211(l)[4] and Guidance Document] ww minimum 2 distribution lines [310 CMR 15.252(2)(a)] Maximum separation between lines 6' [310 CM R15.252(2)(d)] Maximum separation between lines and outside of bed 4' [310 CMR 15.252(2)(e)] Aggregate depth below discharge pipes 6" minimum, 12" maximum. [310 CMR 15.252(2)(g)] Separation between beds 10' minimum. [310 CMR 15.252(2)(0] Bottom area used in calculations only 310 CMR 15.2152(2)(1)] Address l I Pk o M Sty Sheet 5 of 7 I N/A OK NO Pressure Dosed System ? Provided pump and piping calculations as required 310 CMR 15.220(4)(r)] Pressure dosing required on all systems>2000gpd or alternative systems under remedial approval [310 CMR 15.254(2) and I/A J Remedial Use Approvals] If used in gravelless system- make sure jet is directed as not to / scour soil interface [Guidance Document] ✓ Inspections once per year(systems<2000 gpd) or quarterly / (>2000 d) good to note on plan [310 CMR 15.254(2)(d)] J Construction in fill - Did the plan specify that the fill shall meet the specification of 310 CMR 15.255 3 ? ✓ Impervious barrier and/or retaining wall ? Guidance Document Impervious barrier installation must be supervised by designer 310 CMR 15.255(2)(b)] Retaining wall must be designed by Registered Professional Engineer 310 CMR 15.255(2)(a)] Side slope not exceed 3:1 ? [310 CMR 15.255(2)] Breakout requirements met? [310 CMR 15.252(2) and Guidance Document] At least 5 ft. from impervious barrier to edge of SAS (10 ft. / recommended) [310 CMR 15.255 (2)(e)] J Check DEP Approval letters for credits and designconditions If used with pressure dosing do not allow pressure discharge to scour soil interface Was DEP Approval Letter provided and/or have you / reviewed the letter for conditions? Is the technology being properly applied and does it meet all / DEP Approval Conditions? Is there a note on the plan regarding the requirement for perpetual maintenance a reement? Any alarms involved on separate circuits Did the applicant submit an operation and maintenance J manual? �T Has 22plicant submitted a coa of a maintenance MIX Are the variances listed on the plan ? [310 CMR 15.220 4 RLS Stamp necessary on plan if a component is within five / feet of property line [310 CMR 15.412(4)] ✓ New construction or increased flow proposed - [Refer to 310 ✓ CMR 15.414] Address 161 Sheet 6 of 7 N/A OK NO Is the system in a Designated Nitrogen Sensitive Area(Zone II for a public supply well)? [310 CMR 15.214, 310 CMR 15.215 and / 310 CMR 15.216 - also refer to Policy regarding upgrades of such existing systems] Is the system proposed on the same lot as served by private well ? / [310 CMR 15.214(2)] Are the nitrogen loads proposed in compliance? [310 CMR / 15.216(1)] ✓ 'kd' t t"3f 4d��' ..�' a r ^�. ,y✓`%„ �, ,{` �,�Nt 'h- v x�.,�,:v a y f4w �.>. � � � Pumping to se tic tank? 310 CMR 15.229 Shared System 310 CMR 15.290] Address `�t► J�''` S�e Sheet 7 of 7 I Town of Barnstable Regulatory Services Richard V. Scali,Interim Director + BARN3fABLE, Public Health Division i639. °i Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer &Designer Certification Form Date: � Sewage Permit# 0 = 2-0 3 Assessor's Map\Parcel (�s Designer: �,� A- T `� Installer: � S Address: PO fib IC Address: `'I L 0 A i Af r S kc m& C 1M.1, MA U z L � nI i On G J t1C S was issued a permit to install a (date) (in taller) q� septic system at I PLV^ Sf . f jAQI-V, based on a design drawn by jj (address) dated (e '2-21 1 ,- / (designer) I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. Strip out (if required) was inspected and the soils were found satisfactory. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system)but in accordance with State & Local Regulations. Plan revision or certified as-built by designer to follow. Strip out(if required)was inspected and the soils were found satisfactory. I certify that the sy em referenced above was constructed in compliance with the terms of° e IAA approv letters (if applicable) SN OF Mqs U DA J. (I stall s Signature) 1 0. (Designer's ignature) (Affix Desi re) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q:\Septic\Designer Certification Form Rev 8-14-13.doc C Town of Barnstable Departineot of Regulatory Services Public Health Division b S :ry M� Date �,,,•,� sa3Y• 200 Main Street,Hyannis MA 02601 ' �EIJ lM't A Date Scheduled Time .. I M Fee Pd. kiyv Soil Suiiability Assessment for Se age Disposal Performed By:. Witnessed By: LOCATION&GENERAL FORMATION Location Address / /�L�� „� Owner's Name ° (� I_ �— // /4La�J 0 avts (n!2 /3A-r^15 l�D� Addressn Assessor's Map/Peres I ` 161 /" 1� GA/t /�A �/�• 9 5- / 0 — Engineer's Name �� NEW CONSTRUCTION REPAIR ✓ LWL64 19l lam. Telephone$ Z? Land Use L�l 1F slopes M. 0O'o a Surface Stones . O Distanceh fiom: Open Water Body b 0 ft possible Wot Area 3170 i ft Drinking Water Well .�71 So ft Drainsgo Way ft Property Line _ i ft Other ft SIB'TCH:(Street name,dimensions of lot,exact locations of test holes&pere tests,locate wetlands in proximity to holes) To- 2 yC�S`j Ir15Co • �1t.tvG N Parent material(geologic) cla,CLAI Depth to Bedrock >�-00 i Depth to Groundwater. Standing Water in Hole: A • Weeping fl'am Pit Faae Estimated Seasonal High Oroundwater DETERMINATION FOR SEASONAL-HIGT WATER TABLE Method Used: Depth Observed,standing in obs.hole: Depth to weeping In. Depth to soil mottles: p g frorn side of obs.bole: In, ©roundwater Adjustment Ili. Index Well# Reading Data: Index Well level fl ..r._ Act.factor _Adj.ptxtundwater Level Observation PERCOLATION TEST • Hole# p ` Time at 9" Depth of Pero T �~ � -� Time at 6" Start Pro-soak Time @ Time(9"•6") Rod Pro-soak � — V Rate Min./luch . Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N) Original: Public Heallb Division Observtitlon Hole Data To Be Completed on Back— ***Yf percolation test is to be conducted within 100' of wetland,you must first notify the Barnstable Conservation Division at least one(1)week prior to beginning, ,n Q:ISEPI9C\PERC170RM.DOC DEEP.OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Sdil Color Soil. Other Surfaca(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders. coy al o cy,96'Orayell o CLS 1 D.i(-,'0 k. o- 10 C, l.S 0 �► '-to - 132 Cz -C• r�o� . L� ` (t,-'�� 'J�°�6 Gam.,,-�.� DEEP 013SER_VATION HOLE LOG HOle# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. ConsistencV. y -I S� ib,1207, �- iy 3 • ��-5 o s�sl� � CI 41 -131 Gt. -LSit 10 14', G-a\, l + • V 4 DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Conslatency. DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,SSopes;Boulders, ConsistencV. d Flood Insurance Rate Mau; % Above 500 year flood boundary No Yes Within 500 year boundary No 7/1 Yea Within 100 year flood boundary No. Yee Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervi s material oxist in all areas obaerved thrgughout the area proposed for the soil absorption syatem7 If not,what is the depth of naturally occurring pert/ous mat'erlall Certification I certify that on v 0-D (date)I have passed the soil evaluator examination approved by the Department of En ironmental Protection and that the above analysts was performed by me consistent with . described in 10 CMR 15.017. the required trains g,expertise and experienced a � Signatur Date S' Q-\9EPTIC\PERCP0RM.D0C CERTIFICATE OF ANALYSIS Page. 1 10 1 �9 Barnstable County Health Laboratory (:4ILI�^ Report Prepared For: Report Dated: 6/l/2009 Sally Desmond Desmond Well Drilling Order No.: G0951793 P O Box 2783 Orleans, MA 02653 Laboratory ID#: 0951793-01 Description: Water-Drinking Water Sample#: Sampling Location: 161 Plum St.West Barnstable,MA Collected: 5/27/2009 Collected by: Customer Received: 5/28/2009 Routine ITEM RESULT UNITS RL MCL Method# Analyst Tested Note i Nitrate as Nitrogen 10 mg/L 0.10 10 EPA 300.0 LAP 5/28/2009 i Copper ND mg/L 0.0030 1.3 EPA 200.7 LAP 5/29/2009 Iron 0.29 mg/L 0.10 0.3 EPA 200.7 LAP 5/29/2009 Sodium 19 mg/L 1.0 20 EPA 200.7 LAP 5/29/2009 Total Coliform Absent P/A 0 0 SM9223 AF 5/28/2009 Conductance 220 umohs/cm 2.0 EPA 120.1 DCB 5/28/2009 pH 6.5 pH-units 0 SM 4500 H-B DCB 5/28/2009 Nitrate level is at the recommended maximum contamination level for drinking water_Retesting is recommended. Attached please find the laboratory certified parameter list. Approved By: 1� 7 (Lab Manager) < / .may t T' t C t J > CD Crl ND=None Detected RL = Reporting Limit MCL=Maximum Contaminant Level Superior Court House, PO.Box 427, Barnstable, MA 02630 Ph: 508-375-6605 y°FNtis CERTIFICATE OF ANALYSIS �•' `, ,o age: 1 M' Report For: Barnstable County Health Laboratory 9ss�etivsw�% Sally Desmond Report Dated: 6/l/2009 Desmond Well Drilling Order No.: G0951793 P O Box 2783 Orleans, MA 02653 Laboratory 1D#: 0951793-01 Description: Water-Drinking Water Sample#: Sampling Location 161 Plum St.West Barnstable,MA Collected: 5/27/2009 Collected by: Customer Received: 5/28/2009 EPA 524.2- Volatile Organics by GC/MS ITEM RESULT UNITS RL MCL Method# Analyst Tested Note DichIorodifluoromethane ND ug/L 0.50 EPA 524.2 yn 5/28/2009 Chloromethane ND ug/L 0.50 EPA 524.2 yn 5/28/2009 Vinyl chloride ND ug/L 0.50 2.0 EPA 524.2 yn 5/28/2009 Bromomethane ND ug/L 0.50 EPA 524.2 y11 5/28/2009 1,1,1,2-Tetrachloroethane ND ug/L 0.50 EPA 524.2 yn 5/28/2009 1,1,1-Trichloroethane ND ug/L 0.50 200 EPA 524.2 yn 5/28/2009 1,1,2,2-Tetrachloroethane ND ug/L 0.50 EPA 524.2 yn 5/28/2009 1,1,2-Trichloroethane ND ug/L 0.50 5.0 EPA 524.2 yn 5/28/2009 1,1-Dichloroethane ND ug/L 0.50 EPA 524.2 yn 5/28/2009 1,1-Dichloroethene ND ug/L 0.50 7.0 EPA 524.2 yn 5/28/2009 1,1-Dichloropropane ND ug/L 0.50 EPA 524.2 yn 5/28/2009 1,2,3-Trichlorobenzene ND ug/L 0.50 EPA 524.2 yn 5/28/2009 1,2,3-Trichloropropane ND ug/L 0.50 EPA 524.2 yn 5/28/2009 1,2,4-Trichlorobenzene ND ug/L 0.50 70 EPA 524.2 yn 5/28/2009 1,2,4-Trimethylbenzene ND ug/L 0.50 EPA 524.2 yn 5/28/2009 1,2-Dibromo-3-chloropropane ND ug/L 0.50 EPA 524.2 yn 5/28/2009 "- 1,2-Dibromoethane(EDB) ND ug/L 0.50 EPA 524.2 yn 5/28/2009 1,2-Dichlorobenzene ND ug/L 0.50 600 EPA 524.2 yn 5/28/2009 1,2-Dichloroethane ND ug/L 0.50 5.0 EPA 524.2 yn 5/28/2009 1,2-Dichloropropane ND ug/L 0.50 EPA 524.2 yn 5/28/2009 1,3,5-Trimethylbenzene ND ug/L 0.50 EPA 524.2 yn 5/28/2009 i, '.D c�,-, ,.- ii 91i 0.50 EPA 524.2 yn 5/22/2009 1,3-Dichloropropane ND ug/L 0.50 EPA 524.2 + yn 5/28/2009 1,4-Dichlorobenzene ND ug/L 0.50 5.0 EPA 524.2 yn 5/28/2009 2,2-Dichloropropane ND ug/L 0.50 EPA 524.2 yn 5/28/2009 2-Chlorotoluene ND ug/L 0.50 EPA 524.2 yn 5/28/2009 4-Chlorotoluene ND ug/L 0.50 EPA 524.2 yn 5/28/2009 Benzene ND ug/L 0.50 5.0 EPA 524.2 yn 5/28/2009 Bromobenzene ND ug/L 0.50 EPA 524.2 yn 5/28/2009 Bromochloromethane ND ug/L 0.50 EPA 524.2 yn 5/28/2009 Bromodichloromethane ND ug/L 0.50 EPA 524.2 yn 5/28/2009 Bromoform ND ug/L 0.50 EPA 524.2 yn 5/28/2009 Carbon tetrachloride ND ug/L 0.50 5.0 EPA 524.2 yn 5/28/2009 ND=None Detected RL = Reporting Limit MCL=Maximum Contaminant Level Superior Court House, PO.Box 427, Barnstable, MA 02630 Ph: 508-375-6605 -i CERTIFICATE OF ANALYSIS Page: 2 � Yl, Report For: Barnstable County Health Laboratory "cri�,�a�ysw; Sally Desmond Report Dated: 6/I/2009 Desmond Well Drilling Order No.: G0951793 P O Box 2783 Orleans, MA 02653 Laboratory 1D#: 0951793-01 Description: Water-Drinking Water Sample 4: Sampling Location 161 Plum St.West Barnstable,MA Collected: 5/27/2009 Collected by: Customer Received: 5/28/2009 EPA 524.2- Volatile Organics by GUMS ITEM RESULT UNITS RL MCL Method# Analyst Tested Note Chlorobenzene ND ug/L 0.50 100 EPA 524.2 yn 5/28/2009 Chloroethane ND ug/L 0.50 EPA 524.2 yn 5/28/2009 Chloroform 0.73 ug/L 0.50 80 EPA 524.2 yn 5/28/2009 cis-i,2-Dichloroethene ND ug/L 0.50 70 EPA 524.2 yn 5 28/2009 cis-1,3-Dichloropropene ND ug/L 0.50 EPA 524.2 yn 5/28/2009 Dibromochloromethane ND ug/L 0.50 EPA 524.2 yn 5/28/2009 Dibromomethane ND ug/L 0.50 EPA 524.2 yn 5/28/2009 Ethylbenzene ND ug/L 0.50 700 EPA 524.2 yn 5/28/2009 Hexachlorobutadiene ND ug/L 0.50 EPA 524.2 yn 5/28/2009 Isopropylbenzene ND ug/L 0.50 EPA 524.2 yn 5/28/2009 Methylene chloride ND ug/L 0.50 5.0 EPA 524.2 yn 5/28/2009 M ethyl-tert-butyl ether ND ug/L 0.50 EPA 524.2 yn 5/28/2009 Naphthalene ND ug/L 0.50 EPA 524.2 yn 5/28/2009 n-Butylbenzene ND ug/L 0.50 EPA 524.2 yn 5/28/2009 _ n-Propylbenzene ND ug/L 0.50 EPA 524.2 yn 5/28/2009 p-Isopropyltoluene ND ug/L 0.50 EPA 524.2 yn 5/28/2009 sec-Butylbenzene ND ug/L 0.50 EPA 524.2 yn 5/28/2009 Styrene ND ug/L 0.50 100 EPA 524.2 yn 5/28/2009 tert-ButyIbenzene ND ug/L 0.50 EPA 524.2 yn 5/28/2009 Tetrachloroethene ND ug/L 0.50 5.0 EPA 524.2 yn 5/28/2009 Toluene ND ug/L 0.50 1000 EPA 524.2 yn 5/28/2009 Total-;y 12uEs ,VI>* ug/L 0.50 10000 EPA 524.2 yn 5/28/2009 trans-1,2-Dichloroethene ND ug/L 0.50 100 EPA 524.2 yn 5/28/2009 trans-1,3-Dichloropropene ND ug/L 0.50 EPA 524.2 yn 5/28/2009 Trichloroethene ND ug/L 0.50 5.0 EPA 524.2 yn 5/28/2009 Trichlorofluoromethane ND ug/L 0.50 EPA 524.2 yn 5/28/2009 Nitrate level is at the recommended maximum contamination level for drinking water.Retesting is recommended Attached please find the laboratory certified parameter list. Approved B �rectr)) ( X, �o ND=None Detected RL = Reporting Limit MCL=Maximum Contaminant Level Superior Court House, PO. Box 427, Barnstable, MA 02630 Ph: 508-375-6605 . i , dC r Massachusetts Department of Conservation and Recreation Mo.�sa�husen� Office of Water Resources Well Completion Report 04-JUN-09 11:20:48 WELL LOCATION 261211 GPS North: 410 41.4391 GPS West: -700 21.2011 Address: 161, Plum Street Property Owner/Client: Davis Subdivision Name: Mailing Address: 161 Plum Street City/Town: Barnstable City/Town, State:West Barnstable MA Assessors Map: Assessors Lot #: Permit Number:W2009-010 Board of Health permit obtained: Y Date Issued: 05/26/2009 Work Performed Proposed use Drilling Method Overburden Drilling Method Bedrock New Well Domestic Auger CASING From (ft) To (ft) Type Thickness Diameter .00 -86.00 PVC Schedule 40 4.00 SCREEN From (ft) To (ft) Type Slot Size Diameter -86.00 -90.00 Stainless Steel Well .012 4.00 Point WELL SEAL / '.FILTER PACK / ABANDONMENT MATERIAL From (ft) To (ft) Material Description Purpose WELL TEST DATA (ALL SECTIONS MANDATORY FOR PRODUCTION WELLS) Date Method Yield Time Pumped Pumping Level Time to Recover Recovery (GPM) (hrs & min) (Ft. BGS) (Hrs & Min) (Ft. BGS) 05/26/2009 Constant Rate Pump 15.0000 1:30 64.0000 0:01 28 STATIC WATER LEVEL (ALL WELLS) PERMANENT PUMP (IF AVAILABLE) Date Depth Below Ground Pump Description:Starite 1/2HP 10GPM Measured Surface (ft) Type: 2 wire Constant Speed Submersible Intake Depth: 86.0000 05/26/2009 28 Nominal Pump Capacity: 10.0000 Horsepower: .5000 WELL DRILLER'S STATEMENT ADDITIONAL WELL INFORMATION Driller: Thomas E Desmond III Developed: Yes Fracture Enhancement:No Supervisor: Thomas Desmond III Rig #: 137 Disinfected:Yes Well Seal Type:None Firm: Desmond Well Drilling Inc. Total Well Depth: 90.000 Depth to Bedrock: Registration #: 764 Date Complete:05/27/2009 Comments: OVERBURDEN From To Description Color Comment Water Loss/Add Drill Drill (ft) (ft) Zone of Fluid Stem Drop Rate .00 40.00 Silty Sand & Gravel Brown Yes N/A 40.00 50.00 Fine to Coarse Sand Brown Yes N/A 50.00 70.00 Silty Sand & Gravel Brown Yes N/A 70.00 90.00 Fine to Coarse Sand Brown Yes N/A BEDROCK From To Code Comment Water Drill Extra Drill Rust Loss/ :Frac of (ft) (ft) Zone Stem Large Rate Stain Add of Droper No:-=(Aj -- --------- - a _ ` BOARD OF HEALTH :TOWN OF BARNSTABLE Zipplicat ion Ar Veil..Conotruct ion Permit .Application is her made for a permit to Construct (✓), Alter ( ), or Repair ( )an individual Well at: Location — Address Assessors Map and Parcel lan amvL _------ -- Lu ,S : ar � — — Owner Address � s \ ���L--_---_ x 2 CklQ_aS 73 — Installer Driller Address Type of Building Dwelling ----- -- - - ---- - Other - Type of Building---- No. of Persons_`-------_ __. —..... Type of Well y"SCAAub 9V Capacity Purpose of Well YTQZ Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation - The undersigned further agrees not to place the well in operation uT Lertificqe.of Compliance has been issued by the Board of Health. Signed date �1 Application Approved B — --__--___—____—___— date Application Disapproved for the following reasons: --- — -- - ---- -—-—----------- [C"3— --- ----- — date Permit No. :__—�_� - Issued----— � -- --- ---- -------------- date BOARD OF HEALTH TOWN OF BARNSTABLE Certificate Of Compliance THIS IS TO CERTIFY, That the ndividual Well Constructed (J ), Altered ( ), or Repaired ( ) by—_ rn ti1 _ I )11 c -- ---- - -- - --_—_— —__— ---- -Installer at_.__ I �1 __ _�1�f ac�n� �Ol�_ has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation as described in the application for Well Construction Permit No.'k- :14V--Dated S/ice—{-°- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE--_ - Inspector--- - ------------------------- —------ - = 1 ' q o 10 �j No.---------------- . .R_ Fee------ ------------- "' BOARD OF HEALTH TOWN OF BARNSTABLE i 0(ppCicatiori-for Vell Con5trutt ion Permit Application is hereby made for a permit to Construct ( �, Alter ( ), or Repair ( )an individual Well at: AT e Location — Address Assessors Map and Parcel _--r Owner Address �/� _-4 m `�`� l\l\��1 .. .. -Ql�A 1�}+F g� —�Z --------------- Installer —J)riller Address Type`of Building Dwelling -All Other'l. Type of Building--- No. of Persons----------------------_ .; l SC1�Ilo PVC_- rc p y----- T e'of Well - --- �_ m b�C m- YP -- — � Ca acit �-_ __—__-- Purpose of Well Agreemept: The'undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation — The undersigned further agrees not to place the well in, operation un '1 a Certificate .of Compliance has been issued by the Board-of Health. Signed - —--———_-- — -��� Q-----_ • ate Application Approved By — --_—___—_________— o� date Application Disapproved for the following reasons: date Permit No. --__—_____ Issued-------- �)--tia __.—_____ __________ :; r�rwMr�rww11M4w�rww:rrsw+er r.1+M�w.i4wwM���lb Mre�AlrMw w�►M/w,MwWMrrtdl►wryr�4.il.tr�.w�—----------------a--.--7 ..►Y11R�f1N14MMr1r Wb M1l1!!R�l�►Ur,► � BOARD OF HEALTH - TOWN OF BARNSTABLE Certificate Of Compliance THIS IS TO CERTIFY, That the Individual Well Constructed (4), Altered ( ), or Repaired ( ) by—_�S,n,ax�ti ikL_ li I )h / Installer ��u M S �. Q C S ---------------------- at- -— -- - ----- - --- - has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection �}to Regulation as described in the application for Well Construction Permit No. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS Ab GUARANTEE THAT THE WELL -SYSTEM WILL FUNCTION SATISFACTORY. 'ti q t DATE----- -------- - -- : ;Inspector-- - — ------------- -_--_----— - a•a•�•••�r��.��r���•�����•�a�����•••��������*.���w��.`..uw�..w.��•r��������.�a�rr�wr�e•.���A�ao®®��®U�o®®a������e BOARD OF HEALTH TOWN OF BARNSTABLE Ivell Con$trutt ion Permit Oui? No. ------- — Fee —�- --- Permission is hereby granted nks m off' 10 Y� - J to Construct Alter ( ), or Repair ( ) an Individual Well at: ---------------------------------------------------- Street as shown o the application for a Well Construction Permit r No.- D ted 7 5 ��/QA a sfo -------------------------------.. --------- DATE �� � z BoardofHealth ' LOCATION )"' 161 SEWAGE, /PERK-IT NO. 7: 7 VILLAGE INSTALLER'S NAME A ADDRESS d U 1 L D E R OR OWNER DATE PERMIT ISSUED 17- C /cPT DAT E COMPLIANCE ISSUED 1 23 c 2 ` y- S"7 �.o ` w THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH .......................................OF........................................ S, Apsi ir�atiun for DiupuuFal Works Tvitstrurttun Frrutit Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal System at: .... �t _.:5 t.�':}'- '� `S" - - ----------------------------------------------------------------------------------------- Location-Address or Lot No z�. �:..------DAY:`.r........................ .... .f'--s'g. .!►... ..�Z�l.._.._�: Owner Address a ....................... .... = .---.......-•-•-------•--•.................... ...................................................... Installer Address s Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms___.....�.................... .Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building //Z...S ar`� _ No. of persons..... ................... Showers ( ) — Cafeteria ( ) dOther fixtures .------•----•--------------------•-•------------------.-•••••......----•------••-------- ............................................................. Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth-:.-_•--_--.._.. x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) '-� Percolation Test Results Performed by-•---•---•••-•------•----------------•-•---••-•----------------•-------_. Date........................................ a Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water---------- ............. 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 9 ----•-.....•------••---•.............•--•---------••----........--------•--.............--•-------••......................................................... 0 Description of Soil.............................................................•--•-•-•---•...--------•-------------------------------•-............------------••• ...................... W V .........•••--•---••-------------••-•••••-•------------------••---•-----------------•..........•----•----...-----•••----------••--------------••••---•-------------------------------•---•......--••----- W ---------------------- -------------------------------- --------------------------- ----------------------------------------------------------------•--------------------------------------------------- U Nature of Repairs or Alterations—Answer when applicable............................................................................................... ----------------------------•-------•-----•----...-•-------•------------•--•-••----•---••---....................----------------•-----------------...-----------------------•.............-----...------ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the bo d of health. ..._.... --------------------------------------- -- y�at ApplicationApproved By-•••---•---- ---- ------------------------•--------------••--•-----•--•--.................. Date Application Disapproved for the f oll ing reasons-------------•-------------------------------------...---------•----------------•------------------.........-•--- •--------------------•-----------------------------••--••----------------••••-•---------••••----------_.... .................. Date PermitNo......................................................... Issued....................................................... Date -----------------------_--------------------- Fps........................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ------------ - ------ -- --------------OF......................................... Appliratiun for Dispuottl Works Tons rurtion Famit Application is hereby made for a Permit to Construct ) or Repair ( ) an Individual Sewage Disposal System at: 41 43, r Loda�ip Address d� f ori /�` ,4'f•�9wner �.4Y 4.f'......................... ... �. .�a_fg,..-. .... .___._.. �... .... W p� ; i'2t 4t Address �•-� .-------•-- Ai M�lnstaller Address U Type of Bu lding Size Lot----------------------------Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Other—Type e of Building .....___..� yp g �............. No. of persons............................ Showers ( ) — Cafeteria ( ) d Other fixtures ....../. _ .... y - WDesign Flow..........:.................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width..............._._.. Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) 4 Percolation Test Results Performed by......................................................................... Date........................................ 0.4 Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ rs. Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ P14 .••-••••----•----•-••••-•••••-------•-•-.......•--•---•--...------•-•.......................••-••--•......................................................... 0 Description of Soil........................................................................................................................................................................ W --••--•••-------••••-••-•••-••••••-----.....--•-•--••--...-•-•-------•-•-••••----•......-•-----••-•----....-•••••-••-•------••••-•----••-----•-•--•-•-•-•••--•---•••--••----•......•----•--------••.•... ------------------------•-------------------------------------------------------------....----------------------------------------------------------------------------------------------.....--------•-- U Nature of Repairs or Alterations—Answer when applicable............................................................................................... ..........................................................-•----•-•••••••••---•-••...............••--••--•-••--••••••--•-------••---•--••••••-••••••--•••---•••••••••••--.._...-•----•................. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of.TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. ed .... ......................................... Application Approved B ---••-PP PP Y --..... ........................................ Date Application Disapproved for t e f of wing reasons: ........-•-----------------------------------------------•-------•--------•-•--------..........------•---•••-••-••--•-•-•----•••---------•---•---•--------•-••-••-••-••--•--•-•-•-•••-•--•••--••••--•--- Date PermitNo......................................................... Issued_....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF..................................................................................... Cnrdifiratr of Tontphattrr TH' S IS TOOCTIFY, That the Individual Sewage Disposal System constructed ( ) or Repairedby....-• ! ..-•---..... ?. ............ -•-------------------------------------•--------------•---..............-----------....-- ' I 1 , � A at..... ��-'.. --- -- -------- -• --•---------- -- --------- ------- -- ---•------- --- ---- --- ---------•-- --- ----- has been installed in accordance with the provisions of TIP/--5 f le State Sanitary Code as described 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........................................ L.:11..t I............ Inspector--------.... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Fj ...........0 F....................... No........................ FEE......................... Disposal All nntrnr�ion �erntit Permission is hereby granted ....... `' l ' to Construct ( 5__Repa�ian Ind�ividSystem atNo......•-------•--•-• . ... -........................ t.. A Street as shown on the application for Disposal Works Construction Permit No..................... Dated.......................................... --------...-•--••---•---•--------------------•--•-------------------•-••-----...-•-•-••--•••--........._ DATE_ Board of Health FORM 1255 A. M. SULKIN, INC., BOSTON Log Number: 4059 Bottle # D124 Date: 8/23/84 04 BABY BARNSTABLE COUNTY HEALTH DEPARTMENT SUPERIOR COURT HOUSE v BARNSTABLE. MASSACHUSETTS 02630 a � wsa DRINKING WATER LABORATORY ANALYSIS PHONE: 362-2311 EXT. 331 Client: Harold VanDyke f Collector:, Thomas Desmond Mailing Address: 6 Mercury St. Affiliation: T. E. Desmond Well Drilling So. Yarmouth, MA 02664 Time & Date of Collection: 812.1184, 4*00 p.m. Telephone: 896-7065 Type of Supply: well water Sample Location: Plum St. Well Depth: 50' Barnstable Date of Analysis: 8122/84 PARAMETER SAMPLE RESULT RECOMMENDED LIMITS Total Coliform Bacteria/100 ml 0 - f, 0 H 5.8 Conductivity (micromhos/cm 500.0 Iron ( m) 0.10 0.3 Nitrate-Nitrogen ( m) 10.0 Sodium ( m) __ 20.0 I xx 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. Water may present aesthetic problems� (taste, odor, staining) due to 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: Barnstable Board of Health CC: T. E. Desmond Well Drilling Laboratory Dir ctor j"" 7/17/84 Explanation:of. Test Results ti Total Coliform Bacteria Coliform bacteria are an indicator.of the sanitary quality of a water supply. Water supplies may become t , contaminated from malfunctioning septic-systems,cesspools and surface runoff. A total conform 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. result of accidental contamination of the sample bottle through improper sampling methods. For this reason, it would be advisable to retest any well mater 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 acidicin the range of 5.0to 6.5 Conductivity Conductivity is a measure of the dissolved salts in solution. Amounts in excess of 500 mieromhos'cm 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 metherrioglobinemia (an infant disease) and have been suggested to form potentially carcinogenic.nitrosamines. Contamination sources include fertilizers, cesspools and industrial wastes. Coppe r 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: 1 to , J , + - , , 1• �r ' 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 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 Qetting into the well. 20 f f: rn/n. 070 found Go✓e r$ 4"GaSf iron or y_ sch. 40 -V c- pipe /2ma7G. G on c „ s rTii n. pitch % � Goer washed 4:,.i ✓D ,�... ,Lvu ;. Per' ft ^► gminh. Zo pVG pipe pea.st'one pifc17 Val per ff. 41 C/ean f/--- e --- sa n d � ow l;n � -- --- ' inv. el. inV. G/• . • • inv. e inv e% L OGAT/ON Pw7AP x Septic fu.nK inV. a1. - • � '3/.f"- //z SCALE: /•, _ ,• �� �•Ap WctS/7&- •. ,..,:. . ,. .. a o V � . stone prec�.st t�v • leachir,c1 basin ° i Q) SyST� M P/eOF/C. �- or o _„ _ water dab/e el. " �"'-'- /boy'�'orn Pest ho/e e% - �-'• 4 OAS /G /V DATA 7-4r-- ST HOG- LO G AJUMB6P— OF BEO�eOOMS TEST G>fPT& l-� ` 0PRBfAGE O/SPOS/9L UN/T: /mot//7 SSEO BY L TOTfI L-- E19:� T/M19TE O FL-ObAJ PE,2GOL /77 -1 ieATE M//-/. //, /GH � Gf L.`B,e.IfOAY x Be. 6AL.�DAY HOLE 1 HOLE Z �2EQ. SEPT/C TANK GAPFaGITY : GAL. Y/ el= �/ - j el = )V 1 fic.rU,4i L &Ai4L a LEP,G�s�'NG A�EEP l-e~0UI2EMENTS : L - - -- L. S.F. t BOTT0!"l �. ' TDTgL. LEACN/NG CAP/gG /TY /1•07-41RE E �, -- >- r ! /DES 2vE L /9cH//VG CAPAG/TY ,MEN• �r OR/, G/q L. /,/OT S ' y /� ALL Wc�,2KM/q�/SH/P f�N� N7fa7-&Aa1gLS {� SHAL.i_ CoIVFOiE?M TO D. E. Q. & T/TLE• $ c'/ 2 A tit/O T H E 7-0/,VA./ OF 3 4�� 1 fiNC) /eEGULAT/ONS FOB ��i , � � 5UB SURE FAGS p/SPoSF�L OF {{ ' M SAN/ T,q ieY SrLv/9GE-. GnMPC_/,4?A/CE LV/TH ZOti//NG R& GULf17-/0/VS b{{{' { } SHAL[ 3& pETE /2M/NED BY Bt{✓/LID/NG /AJSFPE- C 7-O/2 / G01-17M/5S10AJ&,2. �8 7-0 3) 6EX /ST/n/G �qNo F/NAL G�E'.A,DES SHALL /2EM/9JAj ESSENT/AC-LY B O. OF H�A L.TH .. AGENT V OSS / T GOAJST/eUCT (v 4e^t/r) j L O c A T/o/v { FC- AJCE- : S / T� PLA /V P� EP/9 /e � D Fo/e O/97- �fyp e)Cis-yLin9 Spot a/e✓. O- o o MERA. �^ '► / OA V C OA- CwG 1AJ& E- R 1"G IAVG. ,. -typ. prop. ' �J NUJ. �flr'•� � i 4 5 .3 /e O UT� 134 feSt /70le /OGa�/OrI c 5., �Cr`STE�` . / "'F4s/ SO. L�EN/V/ S , NJASS. OZro 6 O # / 60 / 7 394 88 /0 BARNSTABLE, TOP OF FOUNDATION 24'drarrreter concrete covers EL=5 I.4 raised to wrthin 6'of hmsh grade LEGEND �4-47 (� \\ M A (or as noted) f G8.82 EXISTING SPOT GRADE Fxotrn FL=47./+ EL=45.8± EL=455± 24x5 PROPOSED SPOT GRADE Garrets 'o G / i \i�� �� EXISTING CONTOUR Garage m \ Pond //\/ \//\/ //�/ \ j 24--- PROPOSED CONTOURin o Coop l rn w WATER SERVICE LINE 46.Ot O OVERHEAD UTILITY LINE5 m well Fxrstmg 45.0± 43.2± � u UNDERGROUND UTILITY LINES N MocO Rcl m G GA5 SERVICE LINE GFOTFXTlLF FABRIC Z LOCUS g in (/NPLACEOF//4=//2'PfA57'0N� -� EDGE OF CLEARING IL Fxrstm 44.8+ 44.5± 43.70 43.53 42.40 �V 3/4'- 1-l/2'5TONF FENCE p �; �r Existing O Fv ni 1P SAS Dwelling m g � ' Exrstrng TEST HOLE LOCATION spruce paw Gaszw le -J 00, 40.4o sT 5EPTIC TANK Pond �d TWO(2)5HORPYPRECA5T 500 .5+ DB DISTRIBUTION BOX 1 G lT+ Longest SA5 501L ABSORPTION 5Y5TEM Long 5 85 49'28"W m GALLON LEACH CHAA43FR5 WITH m Route G Existing{ 25 OB-6 l6 4'OP5TONEALLAROUND p n EX/STING 1000 GALLON (l/-20 Rated) (END VIEW) Bottom of rest Hole KEY MAP LEA0-1 SCALE: 1" = 100' SITE LOCUS 5EPTIC TANK D-BDX Cl-�AMBERS 1 CERTIFY THAT I AM CURRENTLY APPROVED BY THE NOT TO SCALE DEPARTMENT OF ENVIRONMENTAL PROTECTION (�F PURSUANT TO 3 10 CMR 15.017 TO CONDUCT SOIL f LOW/�/V I P RO 1 I LE EVALUATIONS AND THAT THE SOIL ANALYSIS HAS BEEN PERFORMED BY ME CONSISTENT WITH THE 1 .) Assessor's Map 195 Parcel 40 NOT TO SCALE REQUIRED TRAINING, EXPERTISE, AND EXPERIENCE 2.) Deed Book 4 149 Pa9e 234 CON 5TRU CT I O N N OTE5 DESCRIBED IN 310 CMR 15,017. 1 FURTHER 3.) Plan Book 3 17 Pa e 34 Lot 4 TEST MOLE LOGS CERTIFY THAT THE RESULTS MY SOIL EVALUATION 9 AS INDICATED ON THE ATTACHED SOIL EVALUATION 4.) This property is not in a Zone II of a Public Water Supply 1.)ALL WORK SHALL CONFORM TO THE STATE ENVIRONMENTAL CODE,TITLE 5 (3 10 CMR 1 5.000): FORM, ARE ACCURATE AND IN ACCORDANCE WITH 5.) This property is in a Town of Barnstable Resource STANDARD REQUIREMENTS FOR THE SITING, CONSTRUCTION, INSPECTION, UPGRADE, AND EXPANSION OF 3 10 CMR 15.100 THROUGH 15.107 Protection Overlay District ON-51TE SEWAGE TREATMENT AND DISPOSAL SYSTEMS AND FOR THE TRANSPORT AND DISPOSAL OF Test Hole#I (EL=45.9±) SEPTAGE,AND THE LOCAL BOARD OF HEALTH REGULATIONS. G.) Flood Zone: C Depth Layer Sod Class Sod Color Comments 2.) ANY SEPTIC SYSTEM COMPONENT INSTALLED IN A LOCATION WHERE THERE 15 POTENTIAL FOR VEHICLES Linda J. Pinto, Certified Soil Evaluator OR HEAVY EQUIPMENT TO PASS OVER IT SHALL BE DESIGNED TO WITHSTAND AN H-20 LOADING. IF UNDER 0"-8" Ap Medium Sandy Loam I OYR 4/2 AN IMPERVIOUS 5URFACE, SYSTEM SHALL BE VENTED TO THE ATMOSPHERE. 8"-20" B Fine Loamy Sand I OYR 5/G 20"-40" C I Medium Loamy Sand I OYR 5/4 3.)TO MINIMIZE UNEVEN SETTLING, SEPTIC TANKS SHALL BE INSTALLED ON A STABLE 40"-132" C2 Medium-Coarse Sand I OYR G/4 50%Gravel Stones F BENCHMARK MECHANICALLY-COMPACTED BASE ON SIX INCHES OF CRUSHED STONE. Top of Bottom Step EL=50.00(Assumed Datum) d5 4.) COVERS OVER THE INLET AND OUTLET TEES OF THE SEPTIC TANK,THE DISTRIBUTION BOX,AND THE SOIL Test Hole#2 (EL=45.9±) f ABSORPTION SYSTEM SHALL BE RAISED TO WITHIN G"OF FINAL GRADE, LEACHING FIELDS,TRENCHES,AND OTHER SOIL ABSORPTION SYSTEMS WITHOUT ACCESS MANHOLES SHALL HAVE AT LEAST ONE(1) 40.E 4S.d Existing Depth L o INSPECTION PORT CONSISTING OF PERFORATED 4"PVC PIPE PLACED VERTICALLY TO THE BOTTOM OF THE ayer Sd Class Sod Co s Color Comment well 501L ABSORPTION SYSTEM WITH A CAP,TIED WITH MAGNETIC MARKING TAPE,ACCESSIBLE TO WITHIN 3"OF O"-9" Ap Medium Sandy Loam 1 OYR 4/2 O FINAL GRADE. 9"-14" B fine Loamy Sand I OYR 5/G N O `' � 14"-41" C I Medium Loamy Sand I OYR 5/4 � > 5.)PIPING SHALL CON515T OF 4"SCHEDULE 40 PVC OR EQUIVALENT. PIPE SHALL BE LAID ON A MINIMUM U to 9 y Existing 4 1"-132" C2 Medwm-Coarse Sand I OYR G/4 50%Gravel Stones cn Gravei Dnve CONTINUOUS GRADE OF NOT LF-55 THAN 2%FROM THE BUILDING TO THE SEPTIC TANK,AND NOT LE55 THAN If) I%OTHERWISE. .. O 49 8 O N 49.5 G.) DISTRIBUTION LINES FOR THE SOIL A85ORPTION SYSTEM SHALL BE 4"DIAMETER SCHEDULE 40 PVC(OR DATE OF TESTING: 05/27/1 5 P#14G97 z EQUIVALENT) LAID AT 0.005 FT/FT. UNLE55 OTHERWISE NOTED. LINES SHALL BE CAPPED AT END OR A5 501L EVALUATOR: LINDA J. PINTO, P.E., OCEANSIDE SEPTIC, INC. NOTED. BOARD OF HEALTH AGENT: DAVE 5TANTON, BARNSTABLE HEALTH DEPARTMENT t0 -fl PERCOLATION RATE: A55UMF LESS THAN 2 MIN/INCH IN "C"LAYER 50 7.) LINES FROM THE DISTRIBUTION BOX TO BE LEVEL FOR THE FIRST TWO(2) FEET BEFORE PITCHING TO THE (PERC'AT TIME OF INSTALLATION) SOIL ABSORPTION SYSTEM. DISTRIBUTION BOX SHALL BE WATER TESTED TO ASSURE EVEN DISTRIBUTION. 50,2 NO GROUNDWATER ENCOUNTERED 8.) GROUT TO BE USED AT ALL POINTS WHERE PIPES ENTER OR LEAVE ALL CONCRETE STRUCTURES IN ORDER e�{rom a TO PROVIDE A WATERTIGHT SEAL. ` 150 0�5 �e\\ 5h / d / 9.) HEAVY EQUIPMENT SHALL NOT BE ALLOWED TO OPERATE OVER THE LIMITS OF THE SEWAGE DISPOSAL 49.s 48.2 FIELD DURING THE COURSE OF CONSTRUCTION OF THE SYSTEM. �5 4 U I0.) IN ACCORDANCE WITH 3 10 CMR 15.22 1.ALL SYSTEM COMPONENTS SHALL BE MARKED WITH to be 25 �rzdd�oN M6A2 2 U MAGNETIC MARKING TAPE. 4' 8.5' 8.5' 4' 10 rr,� I 1.)THERE ARE NO KNOWN WELLS WITHIN 150'OF THE PROPOSED SOIL ABSORPTION SYSTEM. 46.15 46 + � ``... 1ST I � oU o Eri9tmgSept-Components to / 5•g Deck Existing 3 Bedroom 12.) FROM THE DATE OF THE INSTALLATION OF THE 501L ABSORPTION SYSTEM UNTIL RECEIPT OF THE o ;t be Abandoned(See NoteA22) / L 47� / Dwelling U CERTIFICATE OF COMPLIANCE,THE PERIMETER SHALL BE STAKED AND FLAGGED TO PREVENT USE OF THE " fl Top L=51.4± of Foundation E AREA THAT MAY CAUSE DAMAGE TO THE SYSTEM, D Chambers r a m `�6 4"Tree U 13.) THE DESIGNER WILL NOT BE RESPONSIBLE FOR THE SYSTEM AS DESIGNED UNLE55 CONSTRUCTED AS .z a Rt N 45. 46. A SHOWN ON PLAN. ANY CHANGES SHALL BE APPROVED IN WRITING BYTHE DESIGNER. oU / \\ 4 Vacant Land 7 DB Fxastin9 U 14.)THE BOARD OF HEALTH RI QUIRES INSPECTION OF ALL CONSTRUCTION BY AN AGENT OF THE BOARD OF o / o C No Well I !,O' D-Box \ HEALTH AND THE DESIGNER. THE DESIGNER SHALL CERTIFY IN WRITING THAT THE SEWAGE DISPOSAL SYSTEM WAS INSTALLED IN ACCORDANCE WITH THE TERMS OF THE PERMIT AND THE APPROVED PLANS.. 48 HOURS 1 O'mm ADVANCE NOTICE 15 REQUESTED. D-Box TP-2 j 15.)LOCATION OF UTILITIES 15 APPROXIMATE AND CONTRACTOR SHALL BE RESPONSIBLE FOR DETERMINING 6ristrng SeptrcComprrner#s to 45. 2 LOT 4 U F�J� be Removed(See Note r,�'23) 20'mm 4G.2 THE LOCATION OF ALL UNDERGROUND AND OVERHEAD UTILITIES PRIOR TO COMMENCEMENT OF ANY WORK. LAN VIEW V V 46 Area=3G,721 5.F.± TH15 INCLUDES, BUT 15 NOT LIMITED TO, REQUESTS TO DIG5AFE,ANY PRIVATE UTILITY COMPANIES,AND THE ''� LOCAL WATER DEPARTMENT. 5 6 i - - SCALE: I" = 10' a,o ~' o w I GO.00 'Q 1 G.)CONTRACTOR SHALL VERIFY THAT ALL WA5TEUNE5 ARE CONNECTED BY WATER TESTING WITHIN THE DWELLING PRIOR TO INSTALLATION OF ANY SEPTIC COMPONENTS. 45.7 5 85049128"W 17.) CONTRACTOR SHALL VERIFY EXISTING INVERT ELEVATIONS PRIOR TO INSTALLATION OF ANY SEPTIC 46.2 Prepared for: SYSTEM COMPONENTS. SHALL NOT BE USED FOR 46& 47.9 �► Alan Davis Vjr�� �j� 18.) INSTRUMENTSURVEYCONDUCTEDFORPROPOSEDWORKONLY. SITE PIANS SYSTEM DESIGN CALCULATIONS 47.5 IGI Plu STAKING, OR ANY OTHER PURPOSES. m 5t.,tea, MA 19.)THIS PLAN DOES NOT CERTIFY,GUARANTEE OR WARRANTY COMPLIANCE WITH DEEDED OR ZONING OF Pro 05ed Sewa e D15 05al S tem 330GPOREQUJRED F BYLAWS, SPECIFICALLY, BUT NOT LIMITED TO, SIDELINE SETBACKS AND BUILDING HEIGHT RESTRICTIONS. SEWAGE DES/GN FLDWREQU/REO:3 BEDROOM DWELLING !10 GPD/BEDROOM I Sa M p 9 p YS = o I G l Plum St., Bar_n5 ble, M OWNER 15 RESPONSIBLE FOR OBTAINING SUCH A DETERMINATION FROM THE APPROPRIATE AUTHORITY. Ll+ A : 91y '�o p�! .r 20.)TEST HOLES COMPLETED PER STATE ENVIRONMENTAL CODE,TITLE 5. SOILS CAN BE VARIABLESEWAGE DE5/GN FLOW PR0V1DED 7WO(2)500 GALLON LEACH CHAMBER5 WITH V AND IV Prepared by: TEST HOLE DATA IS NO GUARANTEE OF 501L CONDITIONS IN OTHER AREAS. IF SOILS DIFFER'FROM THOSE 4 OF5TONEALL AROUND SHOWN IN THE SOILS LOGS, DE51GN ENGINEER 15 TO INSPECT THE SOILS PRIOR TO PROCEEDING WITH W=j(25.0x /2.63) +2(25.0+ /2,63)x2Jx.74 �FOI INSTALLATION OF ANY SEPTIC COMPONENTS. =349.3 OD PROVIDED -loft --- 2 1.)EXISTING 1000 GALLON SEPTIC TANK TO BE UTILIZED. PVC TEES TO BE INSTALLED ON INLET AND t �- -- 349 GPD PROVIDED>330 GPD REQUIRED OUTLET PIPES IF NECESSARY,AND A GAS BAFFLE INSTALLED IN THE OUTLET TEE. ���D 22.)EXISTING SEPTIC COMPONENTS TO BE LOCATED, PUMPED DRY, FILLED WITH CLEAN SAND AND 5EF'T/C TANK CAPAC/TYREQUIRED: 330 GPDX 200�=660 GPO REQU/RED ABANDONED IN PLACE. AREA TO BE COMPACTED TO MINIMIZE 5ETTLING. 5EPTICTANKCAPACITYPROVIDED: a15TWO /0006ALLON PROVIDED INSPECTION NOTE: O 2O �O �O { 23.)EXISTING SEPTIC COMPONENTS TO BE REMOVED. ANY CONTAMINATED 501L SHALL BE REMOVED FOR A PRIOR TO FINAL INSPECTION BY THE ENGINEER,SYSTEM FWAINFFRINC DIvis!10N DISTANCE OF FIVE(5) FEET LATERALLY FROM THE 501L AB50KPTION SYSTEM AND REPLACED WITH CLEAN A GARBAGED/5P05AL 15 NOTPERM/TTFD WITH 71-1/5 DE5/611/FLOW NEEDS TO BE COMPLETE INCLUDING BUILDUP POP,COVERS. SCALE 1"=20' P.O.Box201, Brewster,MA 02631 Phone:(508)896-I513 SAND. AREA TO BE COMPACTED TO MINIMIZE SETTLING. C:\Ocean5ide\05-Plum\05-Plum-5D5 Plan.dwg Date:OQ1 G/15 Scale: As Shown I By: UP Check:MLA I Project No.051 5140 I