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HomeMy WebLinkAbout0350 PLUM STREET - Health 350 PLUM A= 196 020 001 1 ,t % F " CERTIFICATE OF ANALYSIS Page: 1 of 1 Barnstable County Health Laboratory (M-MA009) 9"ss �yi��stii Report Prepared For: Report.Dated: 3i16/2017 Debbie Crowell Order No.: G179=1 350 Plum St. y W. Barnstable, MA 02668 Laboratory ID#: 1798481-01 Description: Water- Drinking Water I;? Sample#: Sample Location: 350 Plum St.W.Barnstable (toected: 03/15/2017 Collected by: Customer Received: 03/15/2017 I I Test Parameters ITEM RESULT UNITS RL MCL METHOD# ANALYST TESTED NOTE Total Coliform Present P/A 0 0 SM9223 RG 3/15/2017 I Recommended maximum contamination level exceeded due to.Coliform Bacteria. Tested negative for E.coli. Retesting is I recommended. Attached please find the laboratory certified parameter list. Approved By: (Lab. Director) �f ND=None Detected RL = Reporting Limit MCL=Maximum Contaminant Level 3195 Main Street, PO. Box 427, Barnstable, MA 02630 Ph: 508-375-6605 No. j Fee BOARD OF HEALTH TOWN OF BARNSTABLE pplicatiou jf or Yell Cougtructiou permit Application is hereby made for a permit t Constru t( ), Alter( ), or Repair( ) an individual well at: �3 S-0 A PLI -o)o - 00 ) Location-Address Assessors Map and Parcel Owner Address taller-Driller Address Type of Building �f Dwelling I Other-Type of Building No. of Persons type of Well . t�� Capacity Purpose ell_P6 Agreement: The undersigne rees to install the afore described individual well in accordance with the provisions of the Town of Barnstable Bo ealth Private Well Protection Regulation-The undersigned further agrees not to place the well in operation unt' Certificat pliance has been issued by the Board of Health. Signe Dat / Application Approved By A / Application Disapproved for the following reaso CT' 9 Date Permit No. Issued Date BOARD OF HEALTH TOWN OF BARNSTABLE Certificate of Compliance THIS IS TO CERTIFY,that the individual well Constructed( Altered( ), or Repaired( ) by &WXB4amsathas been installed in accordance th the provisions of the Town of r e rivate Well Protection Regulation as described in the application for Well Construction Permit No. ated THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORILY. Date Inspector ---- —_-------------------------------- - No. ! Fee BOARD OF HEALTH TOWN OF BARNSTABLE 2ppltcation _for Vern Cougtruction Permit Application is hereby made for a permitfto Construct( ), Alter( ), or Repair( ) an individual well at: y() P/old 7)t Location-Address Assessors Map and Parcel Owner Address l+ Installer-Driller Address Type of Building Dwelling Other-Type of Building No. of Persons i - Type of Well / " ; Capacity Purpose of Well P6 Agie`einent: The undersigned agrees to install the afore described individual well in accordance with the provisions of the Town of Barnstable Board_of..Health Private Well Protection Regulation-The undersigned further agrees not to place the well in operation unfit-a Certificate,, f> •mpliance has been issued by the Board of Health. Signe j' Dat Application Approved By / / V v /Date Application Disapproved for the following reaso : ' L / Date b Permit No. ✓ Issued r r D e i BOARD OF HEALTH TOWN OF BARNSTABLE s ` Certificate of Compliance j THIS IS TO CERTIFY,that the individual well Constructed( Altered( ), or Repaired( ) by 4,1 (A -IP— � a)6,S_r taUler 9✓ at has been installed in accordance With the provisions of the Town of Barns ablerM, e t 'Private Well Protection Regulation as described in the application for Well Construction Permit No. P1 . ,ated -VVV(/ P THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORILY. Date Inspector -------------------------------.---------------------------------es--------------a ------------ BOARD OF HEALTH TOWN OF BARNSTABLE Vern Cow5tructiort Permit No. 1 OC6 Fee Permission is hereby granted to _A)l 0,4,/ 1, dX,,, r Installer to Construct( Alter( ), or. Re air ) an,,' div'dual well at _ treet as shown on the pplicati hi for a Well Construction Permit No. Dated as r. Date / 7 Approved By ,' `� Q TOWN OF BARNSTAB\LE Z ATION-5so / 'L Urn 5t �Cd�SSJ SEWAGE #��AGE W48't• -8004Stabtie. ASSESSOR'S MAP & INSTALLER'S NAME&PHONE NO. 64A <<5 E�r'0 S COnSt' i SEPTIC TANK CAPACITY /GDD S q kocyl) LEACHING FACILITY: (type) (size) NO. OF BEDROOMS AA B OR OWNER hY eha e-C, *,A1g17c V V u m)OGr d PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by No. 0 t/�� ( j C I Fee /®®1 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes (� PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS application for Mioaal �pStem (Cott!6truction Permit �. Application for a Permit to Construct( Repair( )Upgrade( )Abandon( ) El Complete System O Individual Components Location Address or Lot No. / ,$p!� j►l vyrw s�. Owner's Name,Address and Tel. o. �/© Assessor's Map/Pazcel /WQ� ! � �� a-�pp Jy �►�lv?c Installer's Name,Address,and Tel.No. 7 Designer's Name,Address and Tel.No. Type of Building: Dwelling No. of Bedrooms / Lot Size sq.ft. Garbage Grinder('10 Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date 1�tlmber of sheets Zisio D t_e Title dLZ4, — j;& Size of Septi Tank ��� l'/.J 1 ✓ Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable - aw ' Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of e of the Environ l Code and not to place the system in operation until a Certifi- cate of Compliance has b iss this Board of He Sign Date Application Approved by Date Application Disapproved for the followi reaso Permit No. �Mb i Date Issued / No. Cof(As�C � � Fee © THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: i 1 .,. Yes v A�X01PPUBLi C HEALTH DIVISION -TOWN OF BARNSTABLE} MASSACHUSETTS Application for Mfi5p at *pgtem CCongtruction Permit =� Application for a Permit tovonstruct(.4Repair( )Upgrade( )Abandon( ) O Complete System ❑Individual Components Location Address or Lot No. SO r b Ow er's•N e,Ad ress and Tel.No46� . `., Assessor's Map/Parcel �9f1 /�/J.� 00® � 23S g Ins er's Name,Address,and Tel.No. S S°•'3G$ 6?3y Designer's Name,Address and Tel.No. ��s �jo Type of Building: l Dwelling No.of Bedrooms / Lot Size sq:ft. Garbage Grinder(0 Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 3 3 gallons per day. Calculated daily flow gallons. Plan Date zllumber of sheets evision Date, i Title ' Z� //L✓ ' Size of Septic Tank ��"" mil G Type of S.A.S. Description of Soil Natu of Repgirs or Alterations(A swer w en applicable) i9!✓h' �A�``N/ y 'u , 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 ofiTi e3of the Enviro .men al Code and not to place the system in operation until a Certifi- cate of Compliance has been issued"by this Board of H h. n k Sigrtd;a l / ,,�m� ✓ 7 y_0 r!> Date A Z i Application Approved by ✓!/�G � �'l%' ° r / 't a f' � Date Application Disapproved for the follovying reasons �. Permit No. Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate Kate Of CCOm 1tancE THIS IS TO CERlr10( that he On-six ewage D po ste Cos ed( )Repaired ( )UPgraded( ) Abando ( )> -` at U ligsibe n constructed in accordance with the provi io s of Title 5 and the for Disposal System Construction Permit No dated Installer ` Designer The issuance of this permit shfall, `of construed as a guarantee that the system ili fume ion as_.designed. �. Date 1 ! t Inspector "7'"•--=-'i�"_"'__.- - _. No. d �� �------------------------=Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Mi5po.ZaY *pgtem CCOngtruction Permit Permission is hereby gr to C nstru t( Repair(�Up rade( ) ba don( �) System located atY ����f' 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: Constructi n u t 5e completed within three years of the date of thi e t: /10� �r Date:_.. Approved by. rr 11/14/2005 00:35 95083855314 CBJMW EAST DENNIS PAGE 01 rF JOLY, WABEE & WEINERT REALTY 1582 MAIN STREET EAST DENNIS,MA 02641 PHONE NUMBER: 508-385-5310 FAX NUMBER: 508-385-5314 FAX COVER SHEET r Send To From Barnstable Board of Health Cathy McAbee Attentlon Date Health Inspector November 14 2005 Subject BY well Test on 350 Plum Street, West Barnstable Fax number Phone number 507-790-6304 508-385-5310 Total Pages, Including Dover: 2 COMMEM'S: To whom it may concern: I understand that this well test is now mandatory prior to the transfer of real estate. If you need any additional information from me concerning this test please let me know at the earliest possible time. Thank you, Cathy McAbee 11/14/2005 _00:35 95083855314 CBJMW EAST DENNIS PAGE 02 DS 1hi11i,I&Is FRI 11:49 FAX508 888 6d4t3 EIYVIROTECH LA �rnr�RnrEct��p�TORJBs, INc. MA CFR r rvo.:JW-MA 061 d Jam,seb��Nae lair-Utic s>:' Sp,jdw**, AM 0�.3 888-64N 1.800.,U94 0 FAX(JOB)898-6" Kathy MCA Oe LocAnolr: W a�sbble M ADDRECLIENTSS: Coldwell Banker ADDRESS: p0 Box 1147 E Dennis MA 02641 SAMPLE DATE: 11/10/2005 COLLECTED®Y: Alton/Env SAMPLE 1'►ME: 11 :10 DA r'E RECEIVED: 111I D12005 WATER SAMPLE TYPE: Exisbng Well LAD I.D. 0: 0511153 WEC.LSPECS.: NIA RESULTS OF ANALYSIS: Parameters units Rveo1emmded Rwuhs Method Date Analytad Limits Conform bsatarla I100m1 0 0 92228 11/10/2005 pH pH units 6.5-6.6 5.59 4500 H+ 11/1012005 Conductance umhos/cm 500 145 120.1 11/10/2005 NltratwN mg/L 10.0 <0.01 300.0 11/1012005 Nitrite-N mg/L 1.00 <0,004 30e.0 11/10/2005 Sodium mg/L 20.0 344 200.7 11/1012005 Iron mg/L 03 'CO. 1 200.7 11 II 2009 Manganese mg/L 0.05 0.080 200.7 11110/2005 COMMENTS: Sodium level is not I health Hazard. Manganese is not a health haurd. WATER MEET'S EPA STANDARDS AND IS SUITABLE FOR DRINKING PURPOSES FOR PARAMETERS TESTED. ND a None Detected. <=less than >=greater then TNTC=too numerous to count 4 91 , W-A-1 LA Ro ld J.Saari Laboratory bi 1 OF RA N-tABLZ Z G�NOV !4 PM Z: 20 otVts�v� COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION r V Map:_196_ Lot:_ Par:_20-1_ TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address:_350 Plum St. (main house) W. Barnstable_ , Owner's Name: Nancy&Mike Mumford Owner's Address: _same l Date of Inspection:_I0/12/05 t� Name of Inspector: Dion C.Dugan Company Name:_ 1543 Main St. Mailing Address: Brewster,MA 02631 Telephone Number:_50"9&9390 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: X_ Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: A Date: 10/12/05 The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments: * Recommend septic tank be pumped now.Septic tank be maintenance pumped every 3 years. *Recommend: Maintenance pumping 3—5 yrs. ****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. Page 2 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 350 Plum St. _W. Barnstable_ Owner's Name:_Nancy& Mike Mumford_ Date of Inspection:_10/12/05_ Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: _X_ 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: B. System Conditionally Passes: N/A 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. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfihration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: Page 3 of 1 I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:_350 Plum St. W. Barnstable_ Owner's Name:_Nancy&Mike Mumford_ Date of Inspection:_10/12/05_ C. Further Evaluation is Required by the Board of Health: N/A Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well*".Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: Page 4 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 350 Plum St. W. Barnstable_ Owner's Name:_Nancy&Mike Mumford_ Date of Inspection:_I0/12/05 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No _X_ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _X_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool _X_ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _X_ Liquid depth in cesspool is less than 6"below invert or available volume is less than''/z day flow _X_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _X_ Any portion of the SAS,cesspool or privy is below high ground water elevation. _X_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _X_ Any portion of a cesspool or privy is within a Zone 1 of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well. _X_ 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility 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.] NC (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: N/A To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no _N/A_ the system is within 400 feet of a surface drinking water supply _N/A_ the system is within 200 feet of a tributary to a surface drinking water supply _N/A_ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone If of public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a Page 5 of 1 I significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Prbperty Address: 350 Plum St. _ W. Barnstable_ Owner's Name:_Nancy& Mike Mumford_ Date of Inspection:_10/12/05 Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No _X_ _ Pumping information was provided by the owner,occupant,or Board of Health _X_ Were any of the system components pumped out in the previous two weeks? _X_ _ Has the system received normal flows in the previous two week period? _X_ Have large volumes of water been introduced to the system recently or as part of this inspection _X _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) _X_ _ Was the facility or dwelling inspected for signs of sewage back up? _X_ _ Was the site inspected for signs of break out? _X_ _ Were all system components,excluding the SAS,located on site? _X_ _ 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? _X_ _ 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: Yes no _X_ _ Existing information. For example,a plan at the Board of Health. X _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[3 10 CMR 15.302(3)(b)] 1 Page 6 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 350 Plum St. W. Barnstable_ Owner's Name:_Nancy& Mike Mumford_ Date of Inspection:_10/12/05_ FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):_4_ Number of bedrooms(actual):_4_ DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):_440 gpd_ Number of current residents: 3 Does residence have a garbage_gri_nder(yes or no):_no_ Is laundry on a separate sewage system(yes or no): no[if yes separate inspection required) Laundry system inspected(yes or no):_no Seasonal use:(yes or no):_no Water meter readings; if available(last 2 years usage(gpd)): Well>100'away Sump pump(yes or no):_no_ Last date of occupancy:_OCCUPIED COMMERCIAL/INDUSTRIAL: N/A Type of establishment: N/A Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no):_ Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information:_none on record Was system pumped as part of the inspection(yes or no): NO If yes,volume pumped:_gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM X_Septic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool _Privy NO_Shared system(yes or no)(if yes,attach previous inspection records, if any) _Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) —Tight tank _Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: _installed_6/07/99_(6 years old) B.O.H. Records Page 7 of I I Were sewage odors detected when arriving at the site(yes or no): NO OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 350 Plum St. W. Barnstable_ Owner's Name:_Nancy& Mike Mumford_ Date of Inspection:_10/12/05 BUILDING SEWER(locate on site plan) Depth below grade:_18"_ Materials of construction:_cast iron _X_40 PVC_other(explain): Distance from private water supply well or suction line:_N/A Comments(on condition of joints,venting,evidence of leakage,etc.): _Joints are tight,venting is through the roof,no signs of leakage. SEPTIC TANK:—YES—locate on site plan) Depth below grade:_6"_ Material of construction:—X_concrete_metal_fiberglass__polyethylene _other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions:_1500 Gallon_ Sludge depth.—3" Distance from top of sludge to bottom of outlet tee or baffle: 27"_ Scum thickness:_12" Distance from top of scum to'top of outlet tee or baffle:_6" Distance from bottom of scum to bottom of outlet tee or baffle: 2" How were dimensions-determined:_by tape and rod Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Recommend septic tank be pumped now.Septic tank be maintenance pumped every 3 years.Tank and tees in good condition,no sign of leakage. *Recommend: Maintenance pumping every 3—5 yrs. GREASE TRAP:_N/A—locate on site plan) Depth below grade:_ 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: Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Page 8 of I I OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 350 Plum St. W. Barnstable_ Owner's Name:_Nancy& Mike Mumford_ Date of Inspection:_10/12/03_ TIGHT or HOLDING TANK:_N/A_(tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX:_YES_(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert:_0"_ Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): D-Box is level with some signs of carry over and no signs of leakage PUMP CHAMBER:_N/A_(locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Page 9 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 350 Plum St. W. Barnstable_ Owner's Name:_Nancy&Mike Mumford_ Date of Inspection:_10/12/05_ SOIL ABSORPTION SYSTEM(SAS):_YES_(locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: _X_leaching chambers,number:_seven high capacity infiltrators w/3.5'of stone_ leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.):_no sign of failure. CESSPOOLS:N/A_(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 or no): Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): *Recommend: Maintenance pumping every 3—5 yrs. PRIVY:—N/A(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.): Page 10 of I I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) -C Property Address: 350 Plum St. W. Barnstable_ Owner's Name:_Nancy& Mike Mumford_ Date of Inspection:_10/12/05_ SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet. Locate where public water supply enters the building. 20' 32 b . � 5 �a:c A _ 63 � 2 c A2 J 3 r Page I I of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 350 Plum St.W. Barnstable_ Owner's Name:_Nancy& Mike Mumford_ Date of Inspection:_10/12/05_ SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water_9 feet Please indicate(check)all methods used to determine the high ground water elevation: _X_Obtained from system design plans on record-If checked,date of design plan reviewed: 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: By perk test on 4/27/99;108"deep no groundwater encountered(>4'of separation) SENDER: COMPLETE THIS SECTION COMPLETE THIS SECTION ON DELIVERY ■ Complete items 1,2,and 3.Also complete A. Sig lure ., item 4 if Restricted Delivery is desired. JO Agent ■ Print your name and address on the reverse Addressee so that we can return the card to you. B. Received by(Pri d Na e) C. ate f Delivery ■ Attach this card to the back of the mailpiece, or on the front if space permits. D. Is delivery address different from item 17 es 1. Article Addressed to: If YES,enter delivery address below: ❑ o Mr&Mrs°Michael Mumford 350A Plum Street(Cottage) West Barnstable,MA 02668 3. Service Type ❑Certified Mail ❑Express Mail ❑ Registered ❑ Return Receipt for Merchandise ❑Insured Mail ❑C.O.D. 4. Restricted Delivery?(Extra Fee) ❑Yes 2, Article Number (transfer from service label) PS Form 3811,February 2004 Domestic Return Receipt 102595-02-M-1540 UNITED STATES POSTAL SE,,'IKCE`14 n First-Class Mail' jr Postage&Fees Paid P�1r'? USPS Permit No.G-10 • Sender: Please print�ddr.n/ame, address,.-and ZiP+4-ira:-this.bdz•— I I I PUBLIC HEALTH DIVISI:I ,fOWN1 OF:BARE,,IS'I'_ALE 200 MAIN STREET HYAi,R\TIS, MASS ACHUSETTS 02601. EI I iij! ## jjj iijj jj ## ji ii ff j# ! I C �V f�2 II�E!!!lli�l��llllif3lfl��l�ll�Iifili�l!!!E�li'iifil�liiilltli I I `I CO D • ' Q, x.. .. • co II-q Ir Postage $ •3-1 p26p1 �n 0 Certified Fee n �� �o Return Receipt Fee �y CU P Hsrk 0 (Endorsement Required) /J Q n- Restricted Delivery Fee _D (Endorsement Required) 26 Z r r-I Total Postage&Fees Ln C3 o C'J r�1'f�A, __ f� e h7 mF_�r_.d------------- or PO Box No. V /1 -- --w------------------------------- --------------------- -d- cm scare,zr� LF" rn 4.b�'V !ll 001 G6 O Ei Certified Malt Provides: (asianay)zooz eunr'ooec wjod sd o.Amailing receipt o A unique identifier for your mailpiece d A record of delivery kept by the Postal Service for two years Important Reminders: o Certified Mail may ONLY be combined with First-Class Maile or Priority Mail®. e Certified Mail is not available for any class of international mail. e NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For valuables,please consider Insured or Registered Mail. o For an additional fee,a Return Receipt may be requested to provide proof of delivery.To obtain Return Receipt service,please complete and attach a Return Receipt(PS Form 3811)to the article and add applicable postage to cover the fee.Endorse mailpiece"Return Receipt Requested".To receive a fee waiver for a duplicate return receipt,a USPS®postmark on your Certified Mail receipt is required. o For an additional fee, delivery may be restricted to the addressee or addressee's authorized agent.Advise the clerk or mark the mailpiece with the endorsement"Restricted Delivery o If a postmark on the Certified Mail receipt is desired,please present the arti- cle at the post office for postmarking. If a postmark on the Certified Mail receipt is not needed,detach and affix label with postage and mail. IMPORTANT:Save this receipt and present it when making an inquiry. Internet access to delivery information is not available on mail addressed to APOs and FPOs. 1 t COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION r Map:_196— Lot:_ Par:_20-1_ TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION 'ems Property Address:_350 A Plum St. (cottage) s=. i/ W.Barnstable c� Owner's Name:_Nancy&Mike Mumford Owner's Address: same �lF Date of Inspection:_10/12/05_ r ` Name of Inspector: Dion C.Dugan t Company Name:_ 1543 Main St. ^� Mailing Address: Brewster,MA 02631 Telephone Number:_508-896-9390 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: Passes _X_ Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's.Signature: Date: _10/12/05_ The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments: *Recommend: Maintenance pumping 3—5 yrs. *1,000 gal.septic tank found %empty(leaking; required repair) ****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. Page 2 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 350 A Plum St. (cottage) W. Barnstable Owner's Name:_Nancy& Mike Mumford_ Date of Inspection:_10/12/05_ Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: _N/A_ 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: B. System Conditionally Passes: _YES_ 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. Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please explain. _Y_The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. "A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: l f Page 3 of I I OFFICIAL INS PECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Prol rty Address: 350 A Plum St. (cottage) W. Barnstable_ Owner's Name:_Nancy& Mike Mumford_ Date of Inspection:_10/12/05_ C. Further Evaluation is Required by the Board of Health: N/A Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance *This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: Page 4 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 350 A Plum St. (cottage) W. Barnstable_ Owner's Name:_Nancy& Mike Mumford_ Date of Inspection:_10/12/05 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No _X_ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _X_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool _X_ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _X_ Liquid depth in cesspool is less than 6"below invert or available volume is less than day flow _X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _X_ Any portion of the SAS,cesspool or privy is below high ground water elevation. _X_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _X_ Any portion of a cesspool or privy is within a Zone 1 of a public well. _X_ Any portion of a cesspool or privy is within 50 feet of a private water supply well. _X_ 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility 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.] NO_(Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 3 10 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: N/A To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no _N/A_ the system is within 400 feet of a surface drinking water supply _N/A— the system is within 200 feet of a tributary to a surface drinking water supply _N/A_ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—I WPA)or a mapped Zone 11 of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "Yes"in Section D above the large system has failed. The owner or operator of any large system considered a Page 5 of I I significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. OFFICIAL INSPECTION FORM— NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address:_350 A Plum S`t. (cottage) W. Barnstable_ Owner's Name:_Nancy& Mike Mumford_ Date of Inspection:_10/12/05 Check if the following have been done. You must indicate"yes"or"no"as to each of the following! Yes No _X_ _ Pumping information was provided by the owner,occupant,or Board of Health — _X_ Were any of the system components pumped out in the previous two weeks`' _X_ _ Has the system received normal flows in the previous two week period? _X_ Have large volumes of water been introduced to the system recently or as part of this inspection? _X _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) _X_ _ Was the facility or dwelling inspected for signs of sewage back up? _X_ _ Was the site inspected for signs of break out'! _X_ _ Were all system components,excluding the SAS, located on site _X_ _ 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? _X_ _ 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: Yes no _X_ _ Existing information. For example,a plan at the Board of Health. _X_ _ 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(3)(b)J Page 6 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address:­350 A Plum St. (cottage) W. Barnstable_ Owner's Name:_Nancy& Mike Mumford_ Date of Inspection:_10/12/05_ FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):_1_ Number of bedrooms(actual):_1_ DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):_330 gpd_ Number of current residents: Does residence have a garbage grinder(yes or no):_no_ Is laundry on a separate sewage system(yes or no): no[if yes separate inspection required] Laundry system inspected(yes or no):_no Seasonal use:(yes or no):,no_ Water meter readings,if available(last 2 years usage(gpd)): Well>100'away Sump pump(yes or no): no Last date of occupancy:_OCCUPIED COMMERCIAL/INDUSTRIAL: N/A Type of establishment: N/A Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,ete.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information:_none on record Was system pumped as part of the inspection(yes or no): NO If yes,volume pumped:_gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM X_Septic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool _Privy NO_Shared system(yes or no)(if yes,attach previous inspection records, if any) _Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) —Tight tank _Attach a copy of the DEP approval _Other(describe): Approximate age of all components,date installed(if known)and source of information: —Installed_10/12/94(11 years old) B.O.H. Records Page 7 of I I Were sewage odors detected when arriving at the site(yes or no): NO OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_350 A Plum St. (cottage) —' W. Barnstable_ Owner's Name:_Nancy& Mike Mumford_ Date of Inspection:_10/12/05 BUILDING SEWER(locate on site plan) Depth below grade:_18"_ Materials of construction:_cast iron _X-40 PVC_other(explain): Distance from private water supply well or suction line:_N/A Comments(on condition of joints,venting,evidence of leakage,etc.): _Joints are tight,venting is through the roof,no signs of leakage. SEPTIC TANK:—YES—locate on site plan) Depth below grade:_6"_ Material of construction:_X_concrete_metal_fiberglass_polyethylene other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):—(attach a copy of certificate) Dimensions: 1000 Gallon_ Sludge depth 4" Distance from top of sludge to bottom of outlet tee or baffle: 26"_ Scum thickness:_0" Distance from top of scum to top of outlet tee or baffle:_6" Distance from bottom of scum to bottom of outlet tee or baffle: 14" How were dimensions determined:_by tape and rod Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): *1,000 gal.septic tank found%empty(leaking; required repair).Tank and tees in good condition. *Recommend: Maintenance pumping every 3—5 yrs. GREASE TRAP:—N/A_locate on site plan) Depth below grade:_ 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: Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Page 8 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_350 A Plum St. (cottage) _ _W. Barnstable_ Owner's Name:_]Nancy& Mike Mumford_ Date of Inspection:_10/12/05_ TIGHT or HOLDING TANK:_N/A_(tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: YES_(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert:_0" Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): D-Box is level with some signs of carry over and no signs of leakage PUMP CHAMBER:_N/A (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): I f Page 9 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 350 A Plum St. (cottage) W. Barnstable_ Owner's Name:_Nancy& Mike Mumford_ Date of Inspection:_10/12/05_ SOIL ABSORPTION SYSTEM(SAS):_YES_(locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: _X_leaching chambers,number:_infiltrators w/3'of washed stone._ leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation, etc.):_no sign of failure. CESSPOOLS: N/A—(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 or no): Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): *Recommend: Maintenance pumping every 3—5 yrs. PRIVY:_N/A(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.): f v � Page 10 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 350 A Plum St. (cottage) W. Barnstable_ Owner's Name:_Nancy& Mike Mumford_ Date of Inspection:_10/12/05 SKETCH OF SEWA E DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building. a 350 Gott,46E g �} � C = 14- , v Page 1 I of I I OFFICIAL INSPECTION FORM— NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property-Address: 350 A Plum St. (cottage) W. Barnstable_ Owner's Name:_Nancy& Mike Mumford_ Date of Inspection:_10/12/05_ SITE EXAM Slope Surface water ' Check cellar Shallow wells Estimated depth to ground water_9 feet Please indicate(check)all methods used to determine the high ground water elevation: _X_Obtained from system design plans on record-If checked,date of design plan reviewed: 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: By perk test on 4/27/99, 108"deep no groundwater encountered(4'of separation) /r 4 O ( Q J V A IV - --- - - - Fee------ ------------- BOARD OF HEALTH TOWN OF BARNSTABLE v Applicat ion-*r Well Congtructioni3ermit A� li ation is hereby m �ne for a permit to Construct ( , Alter ( ), or Repair ( )an individual Well at: d----EGG. s------- Location - Address Assessors Map and Parcel IC -------------------------------------------------------- ------------------------------------------------------------- �pOw,neerr a Address �C rfFo✓G�--_��_!_�__G(iC--- 6)& - --- - -------------------------------------------------------------------------------------------- Installer - Driller Address Type of Building &-I*,- Dwelling — -- ----------------------------------------- Other - Type of Building No. of Persons---- ---�2�? YP g ---- --- -- - ---—--- P G Type of Well Capacity---------- -�—��---�'— —-- ---------- - Purpose of Well-----° - - --- __----- 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 un ' a erti ' t f pliance has been issued by the Board of Health. Sign - - - ---- A Q 74cZdate Application Approved By — - -_ date Application Disapproved for the following rea ------- - -- date Permit No. -- Issued----- -- - - --- ----- ------ date '--------------------------.._-_-_-._.._____-_-_ BOARD OF HEALTH TOWN OF BARNSTABLE C ertif icate ®f Compliance THIS IS TO CERTIFY, That the Individual Well Constructed ( ), Altered ( ), or Repaired ( ) by--- — ---- — ----- -- ---- - -- - — Installer at- -— ----- -- — — --------- 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. -----------Dated----THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE----- - - Inspector------------------- ---- ---- ,�-� ilk�_-�-__—.r-�--�- ._..-�-.` - �_-•.m�. _.,s ... .� e.� -s--•^s - M. Y _._ ._.. ._. � - N . - --- Fee------ ----- ------- BOARD OF HEALTH TOWN OF BARNSTABLE , zIpp[ cation-*rWell ConotructionVermit Ap�pli ation is hereby ma a for a permit to Construct(' lter ( ), or Repair ( )an individual Well at: ° Le,,f? s /� �A� - i t 6ocatton Addnss M Assessors Map and Parcel, ----- ---------------------- Owner Address ��rFFosG� f�t� �Q_�.. ------------------- --------------------------------------------------------------------- ---------------- Installer — Driller Address Type of Building Dwelling — -- ----------------------------------------- Other - Type of Building-------------------------- No. of Persons.--- %�G G -es Type of Well------- Capacity--------------------d do Purpose of Well------�(�c ------ 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 un '1-ha Ce ific :of pliance has been issued by the Board of Heealltth. Signe - -- - -------- - � �¢----- A Q date Application Approved By, /� / date Application Disapproved for the following rea n -----------------------____—_____-:___—_— ---------- --- ------------------------- ------------- date----- Permit No.-- —-- -- Issued--- -- -- - - -- ---— ---------- date 4 ejT"4",le4il}i4i4i4i4i eie�. s 7Gliti.iA .e.4 ,4T- � T�lG4 _el����••GQili(�NJ"S�2iW,iQ►7d�!GiliRi9i}ifMil��Yfi14Y�i16RiRifs9."1YYNfbM}i4i4r�6lGeliibblG!!i!►4*blS4MMG�G0�4G9NMdIG►bii'li4G\i�{i�iOeTalc BOARD OF HEALTH TOWN OF BARNSTABLE Certificate Of Compliance THIS IS TO CERTIFY, That,the.Individual Well Constructed ( ), Altered ( ), or Repaired ( ) by------ ------�__�:----- ----------------------------------------------------- Installer at - 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. ----------------Dated THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE----- — --- ---- Inspector-- - - - - - ----------- ti4t?iTsK'4@ bA b!lAhHiTTiif:9i4e$64itPa06l81G4ifGlil�Gl64i4ifi 06464i4fi4ilf!9il6e►sli4GAbtiliRSTGTG�IiTGTO'6Lb}aiTil.�V.1.H61i4698}i►i�^i!�s!{NiTG}4T4!!i444i�ki4G437 iT�i4i4iebe�iT$T i}�5!�b�b}i"� BOARD OF HEALTH TOWN OF BARNSTABLE lVell Construct ion 3permit No. ---- -- ®I Fee-- ---__ Permission is hereby grantedto Construct ( , Alter ( ), or Repair ( ) an Indi id W 11 t: No. ��� - - ----- - - - - �� tr as sho o e plic YA r a Well Construction Permit No._ Dated- ------ - --Q--------- o F --- -- l - Board of eat DATE _. TOWN OF BARNSTABLE 4 LOCATION AU J S SEWAGE # l - 3 3 Y 1� fi VILLAGE 0 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY did L LEACHING FACILITY: (type) (size) /0 S`y /a" NO.OF BEDR 7 / BUILDER O OWNE U✓IA PERMTTDATE: 7—1 — 9 COMPLIANCE DATE: 1J 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 r;r`r � �l .OWN-OF BARNSTABLE LOCATIOMO u rA��S SEWAGE# / 7"__,,3��3 Y VILLAGEf vt 1�✓'a ASSESSOR'S MAP &LOT �(!� INSTALLER'S NAME&PHONE NO. �dkrn Qa I SEPTIC TANK CAPACITY /Ed d A AL- LEACHING FACILITY: (type) 7 n J, P-46--s (size) 1D X 5`y i< 10 NO.OF BEDROQM5 7 BUILDER O OWNE �t U0A � PERMTr DATE: 7—9 — 21 COMPLIANCE DATE: r 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 (2E�� 6 6 cw 5.b, 9 No.-qq."33 -- ; Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Yication for i5 ont stem Cottgtruction Permit pplication for a Permit to Construct( )Repair( )Upgrade( )Ab don( ) ❑Complete System ❑Individual Components Location Address or Lot No. _.-/ i� 1 p� g wner's Name,Address and Tel.No. Assessor's Map/Parcel _ ©` �t x � L N�1 S h57sK1�G� Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 1C', 14pL-Io EAR L Type of Building: (� Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building G✓ao D f4g1,nZ No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: u 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 Environme al Code and not to place the system in operation until a Certifi- cate of Compliance has been ' ed by this Board of Heal Signe UDate ? v Application Approved by Date Application Disapproved for the following reasons on Permit No. Date Issued No. - $ � ,� Fee i)- --" - THE COMMONWEALTH OF-MASSACHUSETTS f Entered in-computer: Yes ;PUBLIC HEALTH DIVISION TOWN OF BARNSTABLE., MASSACHUSETTS 0(pplication for 3W5po01 *pgtem Cowaruction Permit pplication for a Permit to Construct( )Repair(� )Upgrade( )Abandon( ) El Complete System El Individual Components Location Address or Lot No. p�wob wner's Name,Address and 1Tel.No. Assessor's Map/Parcel 5 Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. LLB , Type of Building: Dwelling No.of Bedrooms Lot Size C��sq.ft. Garba Grinder( ) Other Type of Building li>w o2�t�,� No.of Persons Show s( ) Cafeteria( ) Other Fixtures ,N Design Flow gallons per day. Calculated daily flow 1•' gallons. Plan Date Number of sheets Revision Date Title h Size of Septic Tank Type of S.A.S. Description of Soil i.. Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environme tal Code and not to place the system in operation until a Certifi- cate of Compliance has been ' ed by this Board of Heal - Signe Date�� �'rl Application Approved by _ 4 Date Application Disapproved for the following reasons Permit No. Date Issued ------------------------------_ —e —,------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of (Compliance THIS IS TO CER Y,that he O -s'te Sew a Disposal System Constructed Repaired ( )Upgraded( ) Abando e by atAl. haNated nstructed in accordance with the provisions o Title'., d the for Dispo a' System Construction Permit No. / _.. Installer 3 `; � Designer C The issuance of s 11 not be construed as a guarantee that the s. will function aspe igned. r�. Date Inspector l41 i _ No. Fee O .,// THE COMMONWEALTH OF MASSACHUSETTS i4 PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS 'Wi5po5ar *p5tem Construction Permit Permission is herebyranted=to-Construct g (1' )Repair( Upgrade.( )Abandon System located at 0 �/a M S 1 SNP 'Cr'n-S 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 mpst bp completed within three years of the date of this permit. Date: - / Approved by �/�'�---- 1 r� I .a •` n ` x jw- OM PLAN, [ _ S 3 E: x > w b ]p A4 (� 7 060 0 0 , dry rr40Fl) c olo rT5` ... 460 rl6,P !M nIM •MR•R y MOM ..•. ::...........,..... ..............._:.::.........:. .........._ . TOWN`0i BARNSTABLE. LOC,kTION SEWAGE #::7V- PILLAGE W ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO.SCb 'C-c WALL SEPTIC TANK CAPACITY l.t cM G-r'u — LEACHING FACILITY:(type)� � �`X,,$ vC (size) NO. OF.BEDROOMS- PRIVATE WELL OR PUBLIC WATERP!� c, BUILDER OR OWNER c " DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: n VARIANCE GRANTED: Yes No V- No. `.s`..�...... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE , pphratilan fnr Bivi-paiial Wnrkii Tomitrnrtiun ramit Application is hereby made for a Permit to Construct ( ) or Repair an Individual Sewage Disposal SysteT,at: M _ Oration-Address or Lot No. owner cAd mss >� •N! 55 L � a- - -- (� �Lcs✓ C._.... ..�J ..`7 Installer Address UType of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms.___1______________________________________Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) Other fixtures _______________________________ _ _ W Design Flow.................. .........................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity./OQ A1___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........................................ 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-----------------------------------••-----------------.....--•--•----------------------------------------------------...------...------------------------....--•-•••--- x U W --•-------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------A........ UNature of Repairs or Alterations—Answer when applicable._.._.Q -LC1-U-- ---....cc!. Q Gam._.....----•-- - �1 '�` - �'S Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code —The undersigned further agrees not to place the system in operation until a Certificate of Complia has been issued e oar o ealth. Signed ... .. . . ................................ ........................................ �y Date Application Approved By ...........1..�.. . - - �7T -------------------------------------- r,�°.s'.�to!��..�7 Application Disapproved for the following reasons: - ... .............................. ........................................ � Date Permit No. ...... --------''.. ---- f�." --..------- Issued ------ . .....'.....Iff.....� . Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Certifi ate of Complianre THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired by .... ............ ------.---------------------------------- ----- ..... _... ._ ................... .......... ............. ....... Insrdler .. � . at ...... . . -�---�-v✓� -- k------------�,-.---- .r. S.r > ------------------------------------------------ has been installed in accordance with the provisions of TITL 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. ..... .�ONSTRUE . �,1 ��. ` . dated ��...� THE ISSUANCE OF THIS CERTIFICATE SHALL NOT RE ,A AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE..... ..'' /��.- .... -------------------- Inspector 7 '------ 'y�� - ------- -- ------------------------------------------------------------------ -- J THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE No...l...F `.... � FEE......................... llwvviial Vorkv Tonotrurtian hermit sCO LL Permission is hereby granted-------------------------� --V....---- to Construct ( ) or Repair ( VJan Intlivialual Sewage Disposal System atNo. � : =4' ..........�---f r-,-,� ---------------------- ------------------------------------------------ Street �--� as shown on the application for Disposal Works Construction Permit bo `-----.:--- ,y or Board of Health DATE........... ----.. ...-----.------.7... FORM 36508 HOBBS&WARREN.INC..PUBLISHERS THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliratilan for Di ipmml Works Tomitrnrtion rumit Application is hereby made for a Permit to Construct ( ) or Repair (V�an Individual Sewage Disposal System at: ......... .Sv_._. ..vr-... ------------ ? r. �r� e -------------------------------------------------------------------------------------------------- ('� Location-Address or Lot No. V Owner Ad ress Cj C r c� M S S C G C..sj L, ..c�.. (2 Installer Address UType of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms-------------------------------------------Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons-_-------_-_-_----_------- Showers ( ) — Cafeteria ( ) P4Other fixtures --------------------------------------------------------------------------------------- ---------------•---•--•-•--•--•-•--•--••-••---•••--•--_-•---- W Design Flow--------------------------------------------gallons per person per day. Total daily flow--------------------------------------------gallons. WSeptic Tank—Liquid capacity_If M...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....................................... Test Pit No. 1................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................ (i Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ �+ ----•--•--•--••--------------•----.....------------•----•---•----••--•--------------•--••--•-....---......................................................... ODescription of Soil........................................................................................................................................................................ x w ....................................................•---_-_-.............---•-.---.--•_•__..._-_---•...-•_-_-••�----"--.------......_---...._..-_---_-_--_-_•_-_...._•_•---............-----•-1•--•---• U Nature of Repairs or Alterations—Answer when applicable.-.--.- r_. — :5 -..r cC�..l.�--.-.W t � c�t� �r�-� �•u C °�c ....- ------�..Tn --�-ct (...S----w-----ZE_t.S-�u—j-"... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued e oard of liealth. Signed ......... ------ ---------- � ---------------------------- - ------------------------ ----- Dace Application Approved By ......-... � ...=�..."...... _.. Lr. � ✓_� DateApplication Disapproved for the following reasons: .......................................................................... ........... . ........ .......... ...... ......................................--.........- .......................................-- . ------------ ------- Dare Qy Permit No. ------/./r------ �--�------ Issued .......... ''..If.. Daze ttt