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0374 PLUM STREET - Health
374 Plum Street W. Barnstable F/REnnis A = 196 019 Commonwealth of Massachusetts 1%-679 Title 5 Official Inspection Form Subsurface Sewage'Disposal System Form -Not for Voluntary Assessments _. C 374 Plum St Property Address =3 Wirtanen wner Owner's Name formation is quired for West Barnstable MA 5-15-18 ery page. City/Town State Zip Code Date of Inspection } Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. potent: A. General Information Q hen filling out ( S�W / �J Q(Q/ rms on the `t,tint mputer,use 1. Inspector:. ly the tab key t move your DOUGLAS A BROWN rsor-do not Name of Inspector e the return Y. D.A.BROWN INC Company Name th P.O. BOX 145 Company Address 'G'L'N'1 EF�V9ttt MA city/Town State Zip Code 508-4204534 S14297 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 5-15-18 InspecWts Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Sins"3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System"Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 374 Plum St Property Address Wirtanen wrier Owner's Name formation is quired for West Barnstable MA 5-15-18 very page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 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: At time of inspection this system met all passing requirements.This report can not predict the future performance under the same or increased usage. House has been occupied by only one person. System was installed in 2004. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): Sins•3/13 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts K Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M ' 374 Plum St Property Address Wirtanen wner Owner's Name nfor for is quireded for West Barnstable MA 5-15-18 very page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ElY ElN ElND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 374 Plum St Property Address Wirtanen wner Owner's Name nformequine for is West Barnstable MA 5-15-18 equired for very page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: "*This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 374 Plum St Property Address Wirtanen Owner Owner's Name information is required for West Barnstable MA 5-15-18 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 374 Plum St Property Address Wirtanen Owner Owner's Name information is required for West Barnstable MA 5-15-18 every page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ❑ ® Were all system components, excluding the SAS, located on site? Z ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on- ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 2 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M a 374 Plum St Property Address Wirtanen Owner Owner's Name information is required for West Barnstable MA 5-15-18 every page. City/Town State Zip Code Date of Inspection D. System Information Description: According to as built card system consists of a 1000 gallon septic tank, d-box and 6 hi cap infiltrators in trench formation. Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (include laundry system inspection Y rY Y information in this report.) El Yes ® No Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage d well 9 ( Y 9 (gP ))� Detail: well Sump pump? ❑ Yes ❑ No Last date of occupancy: Date Commerciallindustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-3/13 Title 5 Official Inspection Form:Subsurface,Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 374 Plum St Property Address Wirtanen Owner Owner's Name information is required for West Barnstable MA 5-15-18 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: 2017 Date Other(describe below): General Information Pumping Records: p 9 ec Source of information: owner stated regular pumping by Scott Frank septic Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M , 374 Plum St Property Address Wirtanen Owner Owner's Name information is required for West Barnstable MA 5-15-18 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Tank unknown S.A.S 2004 per as-built. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑ cast iron ❑40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 1.5feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gallon Sludge depth: light to moderate heaviest at inlet end t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 374 Plum St Property Address Wirtanen Owner Owner's Name information is required for West Barnstable MA 5-15-18 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness light 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? scour pole Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank was functioning properly at time of inspection with no signs of back up. If tank has not been pumped in the previous 3 yrs I recommend pumping at time of transfer and every 2-3 yrs there after for maintenance. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 374 Plum St Property Address Wirtanen Owner Owner's Name information is required for West Barnstable MA 5-15-18 every page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M ° 374 Plum St Property Address Wirtanen Owner Owner's Name information is required for West Barnstable MA 5-15-18 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" I 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.): Box was viewed by Scott Frank with a camera and was in working order at time of this inspection. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments , 374 Plum St Property Address Wirtanen Owner Owner's Name information is required for West Barnstable MA 5-15-18 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 6 infiltrators ❑ leaching galleries number: leaching trenches number, length: ❑ 9 9 ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system i Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): S.A.S was viewed by Scott Frank with a camera and through the observation port where there was some root infiltration found. When viewed with the camera the chambers were found to be empty with clean stone visible through the walls. The roots were probably from locust trees that have been removed at some point before this inspection. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 374 Plum St Property Address Wirtanen Owner Owner's Name information is required for West Barnstable MA 5-15-18 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Lt5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 374 Plum St ' Property Address Wirtanen Owner Owner's Name information is required for West Barnstable MA 5-15-18 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 374 Plum St Property Address Wirtanen Owner Owners Name information is required for West Barnstable - MA 5-15-18 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cel ar ® Shallow wells Estimated depth to high ground water: 5 feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Design plan and as-built from installer. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 374 Plum St Property Address Wirtanen Owner Owner's Name information is required for West Barnstable MA 5-15-18 every page. Citylrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Assessing As-Built Cards Page 1 of 2 TOWN OF BARNSTABLE LOCATION SEWAGE# �J W.LAGE ASSESSOR'S MAP&LOTH 1-- INSTALLER'S NAME&PHONE NO. S C O J� 17r-c,&V SEPTIC TANK CAPACrrY k kom GCL Cox LEACHING FACILrrY:( pe) r (size) X a �,*O.OF BEDROOMS_ � N CY "'o X 1('41"tAe1,AJ BUILDER OR OWNER PERMrrDATE: lYS j COMPLLANCE DATE: _31 3.P1,9 t.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) )cc V , Feet Edge of Wetland and Leaching Facility(If any wetlands exist p within 300 feet of leaching facility) _\.a2 C `k W^ Feet Furnished by if A Rai s.� it Rio �'Qok as t��a � c►ct�nc�a6 0a o � 1 � hq://www.townofbamstable.us/Assessing/HMdisplay.asp?mappar--196019&seq=1 5/25/2018 BARNSTABLE COUNTY DEPARTMENT OF HEALTH&ENVIRONMENT of Bps ; ;WATER QUALITY.LABORATORY BARNSTABLE SUPERIOR COURTHOUSE o r 3195 MAIN STREET/P.O.Box 427 •BARNSTABLE,MA 02630 PHONE: 50&375-6605 9 FAX: 508-362-7103 �r1,fs H"US��S BOTTLE IDENTIFICATION NUMBER DRINKING WATER ANALYSIS (lab Use only) (PLEASE FOLLOW ALL INSTRUCTIONS ON REVERSE SIDE BEFORE COMPLETING THIS FORM) J� �0 REPORT GOES TO: A SAMPLING DATE:�A� TIME: M re ne COMPANY NAME: SAMPLE COLLECTED BY: ) 1 MAILING ADDRESS: NOV-pox LT SAMPLE LOCATION: *�' Ear oA �V�s � �r ���� CfdPHONE# O FAX: MAP&PARCEL# /1?i4 —0 E-MAIL: TOWN WATER WELL WATERX_WELL DEPTH b FINANCIALLY RESPONSIBLE PARTY: CONTACT NUMBER: BILLING ADDRESS: a IF REQUIRED BY MA DEP,PLEASE PROVIDE THE FOLLOWING INFORMATION: PWS ID: PWS NAME: DEP LOCATION(LOC)ID# DEP LOCATION NAME: PWS CLASS: COM NTNC TNC SAMPLE ACEDIFIED:YES SAMPLE INFORMATION: . (1)(M)ULTIPLE (S)INGLE (2)(R)AW , (F)INISHED (3)ROUTINE SAMPLE(RS) SPECIAL SAMPLE(SS) (4) RESAMPLED:YES' NO CUSTODY TRAN5ER DATE TIME.- Relinquished By: 4k5 .120(3, 00 Received B y 1((p / � ,�o/ COMMENT: _. ANALYSIS REQUESTED: —Lab Use Only— CHECK; ANALYTE . PRESERVATION RESULT UNIT ANALYSIS ENTERED BY REVIEWED DATE &DATE BY&DATE Copper mg/L Iron Yes No mg/L Sodium mg/L . Conductance umols/cm Nitrate HNO3 No mg/L pH Total Coliform THIO:Yes No VOC(524.2) HCL•Yes No ug/L Ammonia H2SO4:YesNo mg/L Other COMMENT: BARNSTABLE COUNTY DEPARTMENT OF HEALTH & ENVIRONMENT BARNSTABLE SUPERIOR COURTHOUSE OF BS V 3195 MAIN STREET/P.O.BOX 427 BARNSTABLE,MASSACHUSETTS 02630 �9ssACHU5���5 PHONE: 508-375-6605 •FAX: 508-362-7103 SAMPLING INSTRUCTIONS FOR PRIVATE WELLS 1. Obtain the sampling bottle(s)from the County Lab or Town Health Department. A 100 mL sterile bottle is for bacteria analysis. If water is chlorinated or smells strong chlorine, a 100 mL sterile bottle with preservative of sodium thiosulfate must be used. 2. It is recommended to use a straight faucet preferably NOT swing-type. 3. Turn on the cold water and let it run for five(5)minutes. 4. Fill the bacteria bottle to well above the 100 mL line. This is critical to ensure that there is enough water to perform the test. Do not place the cap on any surfaces or allow anything(i.. e. faucet,hands, etc.)to touch the inside of the bottle. a. When filling the larger of the two bottles, do not fill the bottle to the very top. Be careful not to touch the inside of the bottle or cap with the faucet,your hands, or anything else. b. Sample must be kept cold after drawing the water. 5. Fill out the reverse side of this form and the labels on all bottles. The laboratory requires accurate and complete information. The lab is not held responsible for damages resulting from lack of or incorrect information given,including phones#'s. Please check off all tests being requested. 6. The charge for a routine well analysis (coliform bacteria,pH,conductivity,iron,nitrate, sodium, and copper) is $30.00. Checks should be made out to Barnstable County.Exact change is required if paying in cash. Additional tests require additional fees. Consult the lab for more information. 7. Samples are accepted Monday—Thursday from 8:00 AM to 4:00 PM. They must be delivered to the lab within 6 hours of collection or 24 hours if refrigerated. NOTES: • Samples for bacteria are not accepted on Friday. • Whirlpool,hot tub and pool samples are accepted ONLY Monday and Tuesday. 8. Completion of tests and results takes 10 business days. Results will be sent in the mail. 9. Special requests, such as results in less than 10 business days, are available for an additional charge. Contact the laboratory for pricing. NOTICE: WATER FROM THE SAME SOURCE CAN PRODUCE CONTRARY RESULTS IF TESTED AT DIFFERENT TIMES AND/OR DIFFERENT LOCATIONS. THE COUNTY OF BARNSTABLE SHALL NOT BE LIABLE FOR DAMAGES RESULTING FROM THE RELIANCE ON RESULTS OF WATER TESTS INACCURATELY PERFORMED. PLEASE COMPLETE REVERSE SIDE OF FORM •'OF NA...k CERTIFICATE OF ANALYSIS 4 ht Barnstable County Health Laboratory (M-MA009) `y�gCHLSctii Recipient: Donna Miorandi Matrix: Water-Drinking Water West Barnstable Petroleum Study Sampled: 03/26/2013 10:07 200 Main Street Received: 03/26/2013 11:34 Collection Address: 374 Plum Street,West Barnstable Hyannis, MA 026C1 Sample Location: 196-019 Order#: G1372876 Description: voc Lab ID: 1372876 04 Date Analyzed: 3/26/2013 @ 10:28 Sample#: Analyst: yn Method: EPA 524.2 Dilution Factor: 1 Comment: Mail to Karen,Allen&Carl Wirtanen,P 0 Box 5 i EPA 524.2- Volatile Organics by GC/MS Result MCL MDL Result M L MDL Parameter ug/L ug/L ug/L Parameter ug/L ug/L ug/L Dichlorodifluoromethane ND 0.50 Chloroform ND 80 0.50 Chloromethane ND 0.50 cis-1,2-Dichloroethene ND 70 0.50 Vinyl chloride ND 2.0 0.50 ds-1,3-Dichloropropene ND 0.50 Bromomethane ND 0.50 Dibromochloromethane ND 0.50 I 1,1,1,2-Tetrachloroethane ND 0.50 Dibromomethane ND 0.50 1,1,1-Thchloroethane ND 200 0.50 Ethylbenzene ND 700 0.50 1,1,2,2-Tetrachloroethane ND 0.50 Hexachlorobutadiene ND 0.50 1,1,2-Trichloroethane ND 5.0 0.50 Isopropylbenzene ND 0.50 1,1-Dichloroethane ND 0.50 Methylene chloride ND 5.0 0.50 1,1-Dichloroethene ND 7.0 0.50 Methyl-tert-butyl ether ND 0.50 1,1-Dichioropropene ND 0.50 Naphthalene ND 0.50 1,2,3-Trichiorobenzene ND 0.50 n-Butylbenzene _ ND 0.50 1,2,3-Thchloropropane ND 0.50 n-Propylbenzene ND 0.50 1,2,4-Trichlorobenzene ND 70 0.50 p-Isopropyltoluene ND 0.50 1,2,4-Trimethylbenzene ND 0.50 sec-Butylbenzene ND 0.50 1,2-Dibromo-3-chloropropane ND 0.50 Styrene ND 100 0.50 1,2-Dibromoethane(EDB) ! ND 0.50 tert-Butylbenzene ND 0.50 1,2-Dichlorobenzene ND 600 0.50 Tetrachloroethene ND 5.0 0.50 1,2-Dichioroethane ND 5.0 0.50 Toluene ND 1000 0.50 1,2-Dichloropropane ND 0.50 Total xylenes ND 10000 0.50 1,3,5-Trimethylbenzene ND 0.50 trans-1,2-Dichloroethene ND 100 0.50 1,3-Dichlorobenzene ND 0.50 trans-1,3-Dichloropropene ND 0.50 1,3-Dichloropropane ND 0.50 Trichloroethene ND 5.0 0.50 1,4-Dichlorobenzene ND 5.0 0.50 Trichlorofluoromethane ND 0.50 2,2 Dichloropropane ND 0.50 Surrogates %Recovered QC Limits(%) 2-Chlorotoluene ND 0.50 4-Chlarotoluene ND o.5o P-Bromofluorobenzene 102% 70 130 1,2-Dichlorobenzene d4 103% 70 130 Benzene ND 5.0 0.50 Bromobenzene ND 0.50 Bromochloromethane ND 0.50 Bromodichloromethane ND 0.50 Bromoform ND 0.50 Carbon tetrachloride ND 5.0 0.50 Chlorobenzene ND 100 0.50 Chloroethane ND o.50 Attached please find the laboratory certified parameter list. Approved B (Lab Director) ND=None Detected RL = Reporting Limit MCL=Maximum Contaminant Level Superior Court House, P0. Box 427, Barnstable, MA 02630 Ph: 608-375-6605 Page 4 of 5 Town of Barnstable THE t Regulatory Services kzlftyd Barnstable Thomas F. Geiler, Director a*AmrAcaMv MAS& Public Health Division I I I E 5�A`�� Thomas McKean, Director 2007 200 Main Street Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 March 22, 2013 Ms. Karen Wirtanen& Mr. Allen Wirtanen& Mr. Carl Wirtanen 374 Plum Street P.O. Box 5 West Barnstable, MA 02668 Dear Wirtanen Family: It has come to the attention of the Town of Barnstable Health Department that there may be a possible groundwater contamination in your area. At this time we request access to your house for the purposes of collecting a water sample from your private well for testing. The testing of your private water well would be without cost to you. I would like to do these tests as soon as possible. Please contact me at this office or my work cell phone (listed below) to arrange a convenient time for me to collect this sample. Thank you for your timely attention to this request. Sincerely, Donna Z. Miorandi, R.S. Health Inspector Town of Barnstable Office: 508-862-4644 or 508-862-4639 (Direct Line) Work cell: 508-294-1394 "FORM 30 C�&W HOBBS&WARREN ,M THE COMMONWEALTH OF MASSACHUSETTS BOARD OF H ALTH CITY/TOWN W DEPARTMENT ADDRESS �A, 50y`0 TELEP ONE Address (��\-- Occupant_ Floor Apartment N No.of Occupants No. of Habitable Rooms No.Sleeping Rooms No. dwelling or rooming units No.Stor Name and address of owner 2I qL✓ Remarks Reg. Vio. YARD Out Bld s.: Fences: Garbage and Rubbish Containers: Drainage Infestation Rats or other: STRUCTURE EXT. Steps,Stairs, Porches: Dual Egress:and Obst'n.: ❑ B ❑ F ❑ M Doors,Windows: ` Roof Gutters, Drains: Walls: .{ Foundation: Chimney: BASEMENT Gen.Sanitation: Dampness: Stairs: Li htin : STRUCTURE INT. Hall,Stairway: Obst'n.: Hall, Floor,Wall,Ceiling: Hall Lighting: Hall Windows: HEATING Chimneys: Central ❑ Y ❑ N Equip. Repair TYPE: Stacks, Flues,Vents: PLUMBING: Supply Line: ❑ MS ❑ ST ❑ P Waste Line: H.W.Tanks Safety and Vent(s) ELECTRICAL Panels, Meters,Cir.: ❑ 110 ❑ 220 Fusing,Grnd.: AMP: Gen.Cond. Distrib. Box: Gen. Basement Wiring: DWELLING UNIT Ventil. L to . Outlets Walls Ceils. Wind. Doors Floors Locks Kitchen Bathroom Pantry Den Living Room Bedroom 1 _ � Bedroom 2 Bedroom 3 Bedroom 4 Hot Water Facil. Sup.Ten., Gas, Oil, Elect..- Stacks, Flues,Vents,Safeties: Kitchen Facilities Sink Stove Bathing,Toilet Facil. Vent., Plumb.,Sanit'n.: Wash Basin, Shower or Tub: Infestation Rats, Mice, Roaches or Other: Egress Dual and Obst'n: General Building Posted Locks on Doors: ONE OR MORE OF THE VIOLATIONS CHECKED ABOVE IS A CONDITION WHICH MAY MATERIALLY IMPAIR THE HEALTH OR SAFETY AND WELL-BEING OF THE OCCUPANT AS DETERMINED BY 105CMR 410.750 OF THE CODE OR THE AUTHORIZED INSPECTOR. (See Over) "THIS INSPECTION REPORT IS SIGNED AND CERTIFIED UNDER THE PAINS AND PENALTIES OF PE INSPECTOR TITLE 1 A.M. DATE � -0 � TIME v P.M. 4 A.M. THE NEXT SCHEDULED REINSPECTION P.M. 410.750: Conditions Deemed to Endanger or Impair Health or Safety The following conditions, when found to exist in residential premises, shall be deemed conditions which may endanger or impair the health, or safety and well-being of a person or persons occupying the premises. This listing is composed of those items which are deemed to always have the potential to endanger or materially impair the health or safety, and well-being of the occupants or the public. Because Chapter II, 105 CMR 410.100 through 410.620 state minimum requirements of fitness for human habitation, any other violation has the potential to fall within this category in any given specific situation but may not do so in every case and therefore is not included in this listing. Failure to include shall in no way be construed as a determination that other violations or conditions may not be found to fall within this category. Nor shall failure to include affect the duty of the local health official to order repair or correction of such violation(s) pursuant to 105 CMR 410.830 through 410.833 nor shall failure to include affect the legal obligation of the person to whom the order is issued to comply with such order. (A) Failure to provide a supply of water sufficient in quantity, pressure and temperature, both hot and cold, to meet the ordinary needs of the occupant in accordance with 105 CMR 410.180 and 410.190 for a period of 24 hours or longer. (B) Failure to provide heat as required by 105 CMR 410.201 or improper venting or use of a space heater or water heater as prohibited by 105 CMR 410.200(B) and 410.202. (C) Shutoff and/or failure to restore electricity or gas. (D) Failure to provide the electrical facilities required by 105 CMR 410.250(B), 410.251(A), 410.253 and the lighting in com- mon area required by 105 CMR 410.254. 1 (E) Failure to provide a safe supply of water. (F) Failure to provide a toilet and maintain a sewage disposal system in operable condition as required by 105 CMR 410.150(A)(1)and 410.300. ' (G) Failure to provide adequate exits, or the obstruction of any exit, passageway or common area caused by any object, including garbage or trash,which prevents egress in case of an emergency 105 CMR 410.450, 410.451 and 410.452. (H) Failure to comply with the security requirements of 105 CMR 410.480(D). (1) Failure to comply with any provisions of 105 CMR 410.600, 410.601 or 410.602 which results in any accumulation of gar- bage, rubbish, filth or other causes of sickness which may provide a food source or harborage for rodents, insects or other pests or otherwise contribute to accidents or to the creation or spread of disease. (J) The presence of leadbased paint on a dwelling or dwelling unit in violation of the Massachusetts Department of Public Health Regulations for Lead Poisoning Prevention and Control, 105 CMR 460.000. (See M.G.L. c. 111 @@ 190 through 199.) (K) Roof,foundation, or other structural defects that may expose the occupant or anyone else to fire, burns, shock, accident or other dangers or impairment to health or safety. (L) Failure to install electrical, plumbing, heating and gas-burning facilities in accordance with accepted plumbing, heating, gas-fitting and electrical wiring standards or failure to maintain such facilties as are required by 105 CMR 410.351 and 410.352, so as to expose the occupant or anyone else to fire, burns, shock, accident or other danger or impairment to health or safety. (M) Any defect in asbestos material used as insulation or covering on a pipe, boiler or furnace which may result in the release of asbestos dust or which may result in the release of powdered, crumbled or pulverized asbestos material in violation of 105 CMR 410.353. (N) Failure to provide a smoke detector required by 105 CMR 410.482. (0) Any of the following conditions which remain uncorrected for a period of five or more days following the notice to or knowledge of the owner of said condition or conditions: (1) Lack of a kitchen sink of sufficient size and capacity for washing dishes and kitchen utensils or lack of a stove and oven or any defect that renders either inoperable. (2) Failure to provide a washbasin and shower or bathtub as required in 105 CMR 410.150(A)(2)_and 410.150(A)(3)or any defect which renders them inoperable. (3) Any defect in the electrical, plumbing or heating system which makes such system or any part thereof in violation of generally accepted plumbing, heating, gasfitting, or electrical wiring standards that do not create an immediate hazard. (4) Failure to maintain a safe handrail or protective railing for every stairway, porch balcony, roof or similar place as required by 105 CMR 410.503(A)and 410.503(B). (5) Failure to eliminate rodents, cockroaches, insect infestations and other pests as required by 105 CMR 410.550. (P) Any other violation of 105 CMR 410.000 not enumerated in 105 CMR 410.750(A)through (0)shall be deemed to be a con- dition which may endanger or materially impair the health or safety and well-being of an occupant upon the failure of the owner to remedy said condition within the time so ordered by the Board of Health. it RECEIVED DATE: '�� o• . ,•:� ...,.. ,�; .FEE:- �.2004. . . . i �A i639,-A`e - • 4. .�� ." . REC.4 BY _ rED MAt TOWN OF BAD U1 B.- HEALTH 141 1 =li'S'tab_1etCHED. DATE s Board 4,,Healt h - _ 200 Main Street,Hyannis MA 02601* - ~ Office: 508-862A644 Susan 0.Rask,R.S. FAX 508-790-6304 Sumner Kaufman,M.S.P.H. Wayne A.Miller,M.D. VARIANCE REQUEST FORM LOCATION Property Address: 3�¢ 1L4L,17 .5-r7ZG—&7— Assessor's 1\•fa-p and Parcel Number: 9G - o/� Size of Lot:_ Wetlands Within 300 Ft. Yes ✓ Business Name: No Subdivision Name: APPLICANT'S NAME: /)LG1 n/ /Z. A/ Phone Did the ownec of the property authorize No you to represent him or her? ;. 1`es t/' �. - .. a _ _ PROPERTY OWNER'S NA,lYIE Y ►rt� , t'a Y 40NTAG"T Pl:+i�SO�Ff r Name woc a Name. Address: -1.V, �' Address: ' s. Phone: Phone: VARIANCE FROM REGULATION(List Reg.) REASON FOR VARIANCE(May attach if more space needed) ky&&, E4--C. rSo/=r ry &1/7CH 177ZCA 77fC 01Z451 /-5 �x c. gv/�7- W2 w1 T7•/ JVe-e LS /�x,n SLtit//IGC' s'�r jS w/na s4-7v r Weu- S 3' /zo�� �>hu/ DSC'7D 5,15, 77J1- 1_5 774C GNt SvL v77v/V To r1-1/S 47 rs r/n/G Cu T D wez.G/NG. NATURE OF WORK: House Addition C3 House Renovation ® Repair of Failed Septic System ChecAllst(to be completed by office stgfrperson receiving variance request application) Four(4)copies of the completed variance request form Four(4)copies of engineered plan submitted(e.g.septic system plans) Four(4)copies of labeled dimensional floor plans submitted(e.g.house plans or restaurant kitchen plans) _ Signed letter stating that the property owner authorized you to represent himther for this request.:. . f Applicant understands that the abutters must be notified.by certified,niail'at leasften days prior to tnectiirg date et applicertt's expense (for Title V and/or local sewage regulation variances only) Full menu submitted•(for grease trap variance requests only) „ ,: t��- Varianc'e'iequest application~fee collected (no fee for lifeguard modification renewals, grease trap variance renewals [same ^owncr/lease�orily],,outside dining variance renewals[same owncrllca a only),and variances to repair failed sewage disposal systems s t [only if no expansion to the building proposed]) Variance request submitted at least 15 days prior to meeting date - - -VARIANCEAPPROVED Susan 0.Rask,RS.,Chairman NOT APPROVED Sumner Kaufman,M.S.P.H. REASON FOR DISAPPROVAL Wayne A-Miller,M.D. Q:\HEALTH\Application Forms\VARIREQ.DQC Town of Barnstable MUMSTAIRM Board of Health AIEDN1°�A P.O. Box 534, Hyannis MA 02601 Office: 508-862-4644 Susan G.Rask,RS. FAX: 508-790-6304 Sumner Kaufman,MSPH Wayne Miller,M.D. February 23, 2004 Edward Kelley, P.L.S. Stetson Hall, R.S. 46 Collie Lane, P.O. Box 51 Cummaquid, MA 02637 w nRE�37 'ImStreetlftBarrstab[e , a �hA �196�-fl19 Dear Mr. Kelley and Mr. Hall: You are granted variances, on behalf of your client, Carolyn Atwood, to install a replacement septic system at 374 Plum Street, West Barnstable. The variances granted are as follows: 310 CMR 15.211 (1): To install a leaching facility five feet away from the property line, in lieu of the required 10 feet separation distance. Part XIV, Section 2.0: To install a leaching facility 100 feet away from a new onsite well, in lieu of the required 150 feet separation distance. Part XIV, Section 2.0: To install a leaching facility 118 feet away from a neighbor's well, in lieu of the required 150 feet separation distance. These variances are granted with the following conditions: (1) No more than three (3) bedrooms maximum are authorized at this property. Dens, study rooms, offices, finished attics, sleeping lofts, and similar-type rooms are considered "bedrooms" according to the MA Department of Environmental Protection. (2) The applicant shall record a properly worded deed restriction, signed by the owner of the property, at the Barnstable County Registry of Deeds restricting the property to three (3) bedrooms maximum. A copy of the recorded deed restriction shall be submitted to the Health Agent prior to obtaining a disposal works construction permit. (3) The septic system shall be installed in strict accordance with the engineered plans dated January 22, 2004. (4) The designing sanitarian shall supervise the construction of the onsite sewage disposal system and shall certify in writing to the Board of Health that the system was installed in substantial compliance with the plans dated January 22, 2004. These variances are granted because the physical constraints at the site severely restrict the location of the soil absorption system due to the small size of the lot of only 10,454 square feet. Also, the groundwater direction flow is to the north, toward the bay, from this area. Therefore, it is believed that the installation of the leaching facility in the area depicted on the plan should not affect the neighbor's well. The proposed system appears to meet the maximum feasible compliance standards contained within Title V. Sin e ely y W n Miller, M.D. Chair an Board of Health Town of Barnstable Wm. Michael Mumford 350 Plum Street West Barnstable,MA 02668 E Feb. 9, 2004 Town of barnstable Board of Health 200 Main St. Hyannis, MA 02601 Dear Sirs, I am writing in regard to the Request for Variance by Allan R. Wirtanen for the property at 374 Plum St., West Barnstable. Our property abuts to the south. We have no objection to the variance for this property, as it seems like the only reasonable course of action. We cannot see how this would have any negative impact on our property. Sincerely, Mike Mu `f d, Nancy Mumford Property owners, 350 Plum St, West Barnstable f s � OFtME T . DATE: t)� • FEE: ■"MABLt3, 1dA99. 1639. 1% REC. BY Town of BarnstablgCHED. DATE: Board of Health 200 Main Street,Hyannis MA 02601 Office: 508-8624644 Susan G.Rask,R.S. FAX 508-790-6304 Sumner Kaufman,M.S.PIL Wayne A Miller,M.D. VARIANCE REQUEST FORM LOCATION Property Address: 314 AGv� 69/Zn/ST/� Assessor's Ma and Parcel Number: �9G = o/ p 1r Size�of Lot: /o ys� Sty, �• Wetlands Within 300 Ft. Yes ✓ Business Name: No Subdivision Name: APPLICANT'S NAME: 4444n/ 2, Phone Did the owner of the property authorize you to represent him or her? Yes v No PROPERTY OWNER'S NAME CONTACT PERSON Name: CAIZo-yA1 /-)T),yoo i7 Name: 8rDk/MZn, Address: 37¢ /'CL"V JAI 6 Address: 136X S/ Phone: Phone: Svv'— 3�`L— G'yJo VARIANCE FROM REGULATION(list Reg.) REASON FOR VARIANCE(May attach If more space needed) 1vL=zc 4-r- :So/=r & Z4,4c;14 4izr4 MI 17"7Z4'7 /s 1?c- �B' wl r7-1 LiniE eXISTiA/G W4-4--c.5 ,fin j-eW/aGr S s CTG`7vT Wt'LL .S"3'L/�oti1 /�h=v �oSC;7� SAS., T1!/3" /_5 5-;,4-,77U/1 Ta r7-1/-5 L''X rS r/MG 4*r4P NATURE OF WORK: House Addition House Renovation N Repair of Failed Septic System Check llst(to be completed by office staff person receiving variance request application) _ Four(4)copies of the completed variance request form Four(4)copies of engineered plan submitted(e.g.septic system plans) Four(4)copies of labeled dimensional floor plats submitted(e.g.house plans or restaurant kitchen plans) Signed letter stating that the property owner authorized you to represent him/her for this request Applicant understands that the abutters must be notified by certified mail at least ten days prior to meeting date at applicant's expense (for Title V and/or local sewage regulation variances only) Full menu submitted(for grease trap variance requests only) Variance request application fee collected (no fee for lifeguard modificition a e.wals,._grease.trap variance renewals [same bwner/leasee only],outside dining variance renewals[same owner/leasee only],and variances to repair failed sewage disposal systems [only if no expansion to the building proposed]) Variance request submitted at least 15 days prior to meeting date VARIANCE APPROVED } `r Susan G.Rask,R.S.,Chairman NOT APPROVED Sumner Kaufman,M.S.P.H. REASON FOR DISAPPROVAL '! Vaytie'A.Miller,M.D. Q:\HEALTH\Application Forms\VARIREQ.DOC � =r i .;N;p�i•,�:'�''1.. .t,. � . i� � � .t.. - ... 1';i.1.:Y,.ti.Y��•��•1w, ��' '•l.��i�. TOWN OF BARN STABLE, MASSACHUSE'tTS ASSESSORS MAPS 133.3 .644C.S 24 i C .11 K'• ea,x Sb v WG3T 3/aTl/ti S. � d$@�'it�ti aZGLB 394C. L16AC 11 n ems_ 2.�0 AG-S 10 C��Tj/c-71i�vE b. Y'��`�•�C.S- b.� p ,�,. 1 A Llfo "'9-1 sr M WEST 5 &;r ♦ S G7>� •104 .50X-$ 14. �o S n s 1.1tAC•! k ® 3r� `ri� �'.r � Iry �,., c p 20-1 � . . . 7.26 LC-S tit �N 1.104C 1 X0 K yo 3q No. Fee------ ---------r BOARD OF HEALTH TOWN OF BARNSTABLE ApplitationArVell Con5tructionpermit A c t*on is,hereby ma onfi rjac je for a permit toC,,. t t 'Alter or Repair ( )an individual Well at: A L a ti Address Assessors Map and Parcel � Owner Address ------ ----—-- .. ... / Installer — Driller Address/' Type of Building Dwelling Other - Type of Building No. of Persons- Type of Well— Capacity Purpose of WellF--- Agreement: The undersigned agrees to install the aforidescribed 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 til ffi at ance has been issued by the Board of Health. Signed Mr 7. Cal;�_A 4e dat Application Approved By datof Application Disapproved for the following reasons: date Permit No. 00 Issued--.-- ate BOARD OF HEALTH TOWN OF BARNSTABLE Certificate Of COMPhance THIS IST.Q CE TI at the Individual Well Constructed (C--61tered or Repaired at '7-/ Installer has been installed in accordance with the provisions of the Town of Barnstable Bpairdo of HeMl�tgrivate Well Protection Regulation as described in the application for Well Construction Permit Nog-00-1— ated THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE Inspector -—---- No.---- a------- '� C Fee-------- BOARD OF HEALTH TOWN OF BARNSTABLE Applicat ion-*r Well Conotructionpermit Ap cat' n is hereby made for a permit to Construct (Alter ( ), or Repair ( )an individual Well at: Location — Address Assessors Map and Parcel Owner Address Installer — Driller Address F Type of Building Dwelling ----- --— -----— jOther - Type of Building--------------------- No. of Persons-------------------------------- I Type of Well—C/ff _--- — ------- Capacity---<_''_ /! —---— ---- Purpose of Well---- , 6 --_-- -- s Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation — The undersigned further agrees not to place the well in operation until C� i i ateSf�+om. Dance has been issued by the Board of Health. Signed - , — — — © date ,f P A roved B . /W- Application PP Y j x4/ Application Disapproved for the following reasons:— -----------------------_-____________—____ —date I' Permit No. 1—!1_� Vl/ -� —� _— Issued - Aate BOARD OF HEALTH " TOWN OF BARNSTABLE Certificate Of Compliance THIS IS-0 CE TI.- /That the Ind'tvi( j dual Well Constructed ( Altered( ), or Repaired ( ) by------- c� �Gv rL c, -------------------------------------------------------------- ----- ' � Installer has been installed in accordance with the provisions of the Town of Barnstable Bo rd of Health Private Well Protection Regulation as described in the application for Well Construction Permit NAM LI'Dated THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. i DATE---------- ---- — Inspector—__------------------------------------ i BOARD OF HEALTH TOWN OF BARNSTABLE Well Congtruct ion Permit Fee , Permission is hereby granted —-to Construct (41)Alter ( , or Repair:39 ( an Individual-We at : o;L9 No. - ----- - - street as shown on;-hee,a'p/plication for a�*Well Construction Permit No.- ( V f i� --- Dated— -— -•— ------- --------------------- Board'of Health DATE— / `�� ___ i� , TOWN OF BA.RNSTA.BLE LOCATION c� tIgy SEWAGE # � Y;i!i AGE G.� ti �(� � ASSESSOR'S MAP & LOT , INSTALLER'S NAME&PHONE.NO. S C C�� /y ASEPTIC TANK CAPACITY k l,�gt k dUCa IS�L- �Cox LEACHING FACILITY: ( pe) G,p� O (size) 0.-OF BEDROOMS C 1- `�t�' UILDER OR OWNER1 �G n �,,,3 t z✓ A...2n PERMITDATE: - 1,2C f Q tCOMPLIANCE DATE: 3Z 30 0 Separation Distance Between the: Ma�amum Adjustedf 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 Sage of Wetland and Leaching Facility(If any wetlands exist �. wide pn 300 feet of leaching facility) T k W\ Feet Furn.!shed bv k r � No. .�p, Fee 1` 'THE COMMONWEALTH OF MASSACH SETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS ZIpprication for Migozaf *pftem Construction Permit Application for a Permit to Construct( )Repair( Upgrade( )Abandon( ) O Complete System ❑Individual Components Location Address or Lot No. 2 , Owner's Name,Address and Tel.No. Assessor's Map/Parcel �7� ' Z P'I. A r I A Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder(y" Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow c 3® gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank QD O Type of S.A.S. Description of Soil ®� �' PlOvN Nature of Repairs r Alterations(Answer when applicable) dU �o r \ � Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been iss by this Board of Health. Signed Date l0 Application Approved by 12,1 Date Application Disapproved for thelfollowing reasons Permit No. 1/ l Date Issued i No. O�-�� Vo UV�C'C'. V'�lrl 4 Fee c.�0 ,* `""`•"°THE COMMONWEALTH OF MASSACHUSETTS. �'" Entered in computer: V "+w r Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLEs-MASSACHUSETTS 2ppfication for Zigogaf *pgtem Conotruction Permit Application for a Permit to Construct(. )Repair( XUpgrade( )Abandon( ) O Complete System El Individual Components Location Address or Lot No. j2`f �wM �— Owner's Name,Address and Tel.No. Assessor's Map/Parcel cc�,, �GJ,ry� I` 6\.2 /"1 Gt, "��� r�� 9l0 rV - Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: ^^II Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder(1"� Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures - Design Flow O gallons per day, Calculated daily flow 3 CO gallons. Plan Date Number�of sheets Revision Date Title Size of Septic Tank e -S ,DoO Type of .A.S. Description of Soil yx—e lOv, , F y4 f Nature of Repairs Or Alterations(Answer when applicable) A d d/ P i Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been iss e# by this Board of Health. -- // Signed - - Date,,"LT/Z Lt/0 t/ Application Approved by '1� �. --j,, r Date 1 v Application Disapproved for the following reasons 4!4 1! f 1 , Permit No. 10 V� f Date Issued -?/.q V 6 t I THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of (Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired (Upgraded( ) Abandoned( )by G,. T— at 7 7 Lf (Pt I-), li_-4 C,1. has been constructed in 'ccordance with the provisions of Title 5 and the for�Disposal System Construction Permit No. Zf�,���-/��? dated Installer r c-)1A, [.( Designer The issuance of this permit shall not be construed as a guarantee that the s tem wil�f}�nction ash esi n d. Date : /m/04 Inspector �/� �l�/ (V2__ . Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION . BARNSTABLEs MASSACHUSETTS Migoof *pgtem Con.5truction Permit Permission is hereby granted to Construct( )Repair(Upgrade( )Abandon( ) System located at and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must b completed within three years of the of this peof this,pe Date: /c�.5 Approved'by-- Town of Barnstable .Of1HE 1ph, Regulatory Services Thomas F. Geiler,Director + BARNSTABLE, ' 9 MASS. g Public Health Division �pr iG39�awe En Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer & Designer Certification Form Date: / Lo Designer: ,[7NV1JyzP Ls, Installer: S C O\-\ �-- Address: ROB -5-1 Address: P —T On L _ 0 (4 5—CCA-,-,,UCwas issued a permit to install a (d dI e) - (installer) septic system at vNM� based on a design drawn by ,r (address) � WARD yGs dated . 3&f®� QQQ�ppp¢�jp(' r6 00 N � I certify iq stem referenced above was installed substantially according to the design, include minor approved changes such as lateral relocation of the distribution box,and/or septic tank. 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. ( taller's Signature) am ETSONd `, 1.. S. No.5 esi er's p Here) fvatu PLEASE RETURN TO BARNSTABLE PUBLIC HEALT ON. 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:Health/Septic/Designer Certification Form �\ COMMONWEALTH OF MASSACHUSETTS �, EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION INSPECTION OFFICIAL LYSPECTION FORM NOT 5 SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A 1K 2 CERTIFICATION Property Address: J GI/tij S E io Oaj. `fOwner's Name: .. 2003Owner's Address: 7 uDate of Inspe�on: /� Oo1L Gf NSTABLEEPT. Name of inspector ( lease p.nnt) ���Gr• • Company Name: , �•��// Mailing Address: Telephone Numbe. �� _ MAP PARCEL ,— CERTIFICATION STATEMENT LOT I certify that 1 have personally inspected the sewage disposal system at this below is true,accurate and complete as of the time of the inspection. address that the information reported training and experience in the n0The inspection was performed based on my proper function and maintenance of on site sewage disposal systems I am a DEP approved system inspector pursuant to Section 15.340 of Title S(310 CMR 15.00q The system; Passes Conditionally Passes Ne er Evaluation by the Local ails ApProving Authority Inspector's Signature: Date: to 019 0 The system inspector shall submit a copy of this inspection report to the DEP)within 30 days of completing this in Appr°ving Authority(Board of Health or gpd or greater,the inspection If the system is a shared system or has a design flow of 10,000 DEP.The original shod be sent to thesystem em wner and copies sent shall submit the the buyerrt to the , regional office of the authority. applicable,and the approving Notes and Continents '"*'This report only describes conditions at the time of ins pection antime.This inspection does not address how the system willunder conditions of use perform inahe future u der,the same or different , i 'Page 2 of 11 OFFICIAL,INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: ��.,� �' Owner. � o .�/� tea 6 6—,,::' Date of Inspection: Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A.�Sy m Passes: , have not found any information which indicates that any of the failure criteria described in 310 CUR or in 310 CAM 15.304 exist Any failure criteria not evaluated are indicated below. Comments: B• Sy/stem Conditionally Passes: , C►ne or more system components as descnbed m reP�ed. The system, upon completion of the r the"Conditional Pass"section need to be replaced or replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determin explain. ed(Y,N,ND)in the for the following statements.if"not determined"please The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally mmineriL unsound exhibits substantial infiltration or exfiitmtion or tank failure is i existing tank is replaced with a complying septic tank as approved by the Health.System will P�inspection if the *A metal septic tank will p inspection if it is structurally sound,indicating that the tank is less than 20 years old is available. not leaking and if a Certificate of Compliance 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 approval of Board of Health): System will Pass inspection if(with 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 pipes) The system will Pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed g r ND explain: 1 Page 3 of 11 -y OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: yt' if f f. �..c _ Owner: Date of Inspection: C.�Furt er Evaluation is Required by the Board of Health: Conairions e.dst which require further evaluation is failing to protect public health,safety or the environment by the Board of Health in order to determine if the system 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303 1 system is not functioning in a manner which wal protect public health,saf ( )@)that the ety and the environment: _ Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 Beet 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 wi surface water supply or tributary to a surface water supply. thin 100 feet of a — 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 bacteria and volatile organic compounds indicates that the DEP certified laboratory,for coliform the presence well is free from pollution from that facility and of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided tha failure criteria are triggered. A copy of the analysis must be attached to this form that no other 3. Other: i Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASS.ESSMMNTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: /1' y /7 Sy- Owner. eQ s S le W Date of Inspection: /o D. System Failure Criteria applicable to all systems: You must indicate`yes"or"no"to each of the following for all inspections: Ye No _ DaCkup of sewage into facility or system component due to overloaded or clogged✓✓ a or ponding of effluent to the surface of the SAS or cesspool ogged SAS or cesspool fund or surface waters due to an overloaded or - mod level in the distribution box above outlet invert due to an overloaded or clogged SAS or wd 1 ✓ depth in cesspool is less than 6"below invert or available volume is less than%:day flow �pun i g more than 4 times in the last year NOT to clogged or pipe(s).Number times �Y portion of the SAS,cesspou;or privy is below high ground water elevation. _ An rtion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface ater supply. rtion of a cesspool or privy is within a Zone 1 of a public well. — _ Y portion of a cesspool or privy is within 50 f — Any portion of a feet of a private water supply well. 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 performed at a DEP certified laboratory,for colifor m bacteria and vola�if eorg�c Qom 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 riteria c are triggered.A copy of the analysis must be attached to this form.] C/G- es/No)The system fails.I have determined that one or more of the above failure criteria described in 310 CMR 15.303,therefore the system fails.'The exist e Health to determine what will be necessarysystem owner should contact the Board of to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility gpd- with a design}low of 10,000 gpd to 15,000 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 4estern 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 Protecti )or a mapped- If Area-IWPA Zone H of a public water supply well pped If you have answered"yes"to any question in Section E the system is considered "Yes" in Section D above the large system has failed The owner or o rator of significant fit'or answered significant threat under Section E or failed under Section D shall u largsyste m considered a 15.304. Thecontact the appropriate regional system owner should lade the system in accordance with 310 CUR � office of the Department. Page S of 11 - OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FO PART B CHECKLIST NOPerty Address; s •[ Owner. (,��p0 �l, �Jl�/� Date of hopecpnn. Check if the b Ig have been done.You most indicate es"or"no"as to each of the followin Yes No — Pumping information was provided by the owner, cc"pa,,4 ur Bwrd of Health t/ Were any of the system components pumped out in the • k previous two veers /Has the system received normal flows in the previous two week period — v Have large volumes of water been ink to the system recently or as part of this inspection Were as built plans of the system obtained and=mined?(If they were not available note as N/A) T Was the facility or dwell mg inspected for si gos of sewage back nP Was the site inspected for signs of break out l.� Were all system components•,excluding the SAS,looted on site Were the septic tank manholes uncov of the baffles or tees,material of �Opened,and the interior of the tank inspected for the condition 0�duneasions,depth of liquid,depth of sludge and depth of scum Was the owner(and fiance of sewage s3'�ms��from owner)provided with information on the proper The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no Existing information_For e.-mmpte,a plan at the Board of Health c/ Determined in the field if( any of the faihire criteria related to Part C is at issue approximation of distance is ale)min in t e field(3)(b)j <Page 6 of 1 I -- OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY SUBSURFACE SEWAGE DISPOSAL SYS ASSESSMENTS TEhi INSPECTION FORM PART C n SYSTEM INFORMATION Property Address; �i /1�2/u 017 ,S Owner. B 4/`/ Date of Inspection: O oZ 9 0 RESIDENTIAL FLOW CONDMONS Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 C fjt 15 203(for ® _ example: 110 gpd x#of bedrooms) Number of current residents. Does residence have a garbage grinder(yes or no): I.a�dry on a separate sewage system(yesor no):IPV[if yes Separate Laundry system inspected(yes or no):,!kV inspection required] Seasonal use: (yes or no): Water meter if available(last 2 years u,, Sump pump(Yes or no): ( ): Last date of occupancy: COMIIERCLUjWDUSTRIAL Type of establishment: Design flow(based on 310 CINR 15.203): epd Basis of design flow(seats/persons/sgft,etc.): Grease&ap present(yes or no).- Industrial waste holding tank present(yes or no): Water waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use. OTHER(describe): P=Ping Records GENERAL WFORMATION Source of information: /f/ Was system part P of the' If yes,volume trOII�' r quantity Reason for pram ---moons—How waquantity pumped Y SYSTEM C/�c tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool Privy Innovative/Alt(yes or no)(if yes,attach previous inspection records,if any tesnative technology. Attach a copy of the current obtained from system owner) operation and maintenance contract to be _Tight tank _Attach a copy of the DEp approval _Other(describe): Approximate age of all Components,date installed(if wn)and source of' ormation: Were sewage odors detected whey arriving at the site(yes or no): i a { f Page 7 of 11 ;. OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL,SYSTEM INSPECTION FORM PART C SYSTEM INF'VrUNIATION(confirmed) Property Address: 064v✓n .S 74- i 7 Owner. vY Date of Inspection; 02 9 BUILDING SEWER gocate on site plan) Depth below grade: Materials of construction _pst iron 40 PVC Distance private water other Comments fr(on condtion off well or suction line: ( ): joints,venting evidence of leakage,etc-): SEPTIC TANK._t (lz on site plan)p } Depth below grade: Material of construction:_concrete_metal _other(explain) _polyethylene If tank is metal list age:_ Is age confirmed by a Certificate of Compliance certificate) P (yes or no):_(ate a copy of Dimensions: Sludge depth: �— — Distance from top off sludge to bottom of outlet tee or bale: Scum knes& Distance from too of scumto 1,,4n LALUAC_ Distance from bottom of scum to bottom of et tee or How were dimensions determined. . Comments(on pumping recommendations,inlet and outlet ' or baffle condition,as mated to outlet i ve evidence of 1�gy condition,structural integrity,liquid levels 0 ovt , f p 4 . G GREASE TRAP--"0 on site plan) Depth below grade:_ Material of construction _concrete _meta( fiber (explain): —fiberglass._polyethylene_other Dimensions: Scum thicJmess: Distance from top of scum top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffi�— Date of last pumping Comments(on pumping recommendations,inlet and outlet tee or baffle condition, as related to outlet invert,evidence of leakage,etc.): 4 structural integrity,liquid levels Page 8 of 11 . OFFICIAL INSPECTION FORM—NOT FOR VOL UNTY SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM 'ASSESSMENTS PART C n SYSTEM FORMATION(continued) PrnPerty Address; Owner. o,� 07,S44 Date of Inspection; d p? TIGHT or HOLDING TANK;L'�(mac must be pmped a,time of ias�ion)(locate on site Depth below grade: plan) Material of constructi'L ooncmte metal fibero=—PoIY�Yleae other(explaia): Dimensions_ Design Flow;_ ffl1lonVday `vim Pint(Yes or no): Alarm level: Date of last pumping Alarm inwoddng order(yes or no). Comments(motion of alarm and float switches,etc.): --------------- DLSTRIBUTION BOX (� t m In ust be opeIIed)(locate on site plan) Depth of liquid level above outlet invest; r7O / Continents(note if box is level and dt jon to outlets leakage' to or out of bo etc.): �l'any evidence of solids carryover, ,p .anydence of kt- PUMP CHAMBER k(iopte on site plan) P4n4s 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 i t 1 i Page 9 of l 1 - uNSrF;LTitulr FORM— SUBSURFACE SEWAGE DISPOSAL SYS VOLUNTARY ASSESSMENTS PART C INSPECTION FORM SYSTEM FORMATION(contimmed) Property Address: 2/g�4 At vh Owner.a�!!i Date of O 7 0 SOIL ABSORPTION SYSTEM(SAS): pocate on site Plan,excavation not regnimQ If SAS not located explain why. Type M 9 number: leaching chambers,number. S� leaching galleries,number._ leaching treacles,number,length: leaching fields,number,dimensions: overflow cesspool,number. innovativetalternative system Type/name of technologyy:Comments(note condition of soil,signs of hydraulic etc.): /� / faihue,level of ponding,damp soil,condition of vegetation, � < < C 5 - , ye r- CESSPOOLS:/� / or ��G H/c' �h!Le (cesspool must be Z— pumped aspen of inspeetion)(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 consmwdon: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding.condition of vegetation;etc.): PRIVY; (locate on site plan) M"!=ials of cons:.-uction. Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation . : ,etc) * Pale 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SURFACE SEWAGE DI SPOSAL SYSTEM INSPEC TION FORM PART C SYSMM FORMATION(oowmx4 Property Adam,w �ry L J J' Owner. Date of Inspec�n; /o SKETCS OF SEWAGE D)<SPOSAL SYSTEM Provide a slmtch of the mvapspoW*Stem- �chmarlm Locate all wills within 100 feet.Locatedes to at lease two p public water supply eaters or the building lint Frv,-4 l✓efi at 93 ' 3 i A'a yv • r Page l l of i t p OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR PART C SYSTEM FORMATION(continued) Pm1erty Address; Owner, � Date of�pection: ! a9 SITE EXAM Slope Surface water, Check cellar Shallow wells Estimated depth to Wound waw Z feet Please ix"cate(check)all methods used to determine the high groin water elevation: Observed site stem design plans on record-If gn Plan reviewed (fig Perry/observation hole�50feet of SAS) Checked with local Board of Heahh.explare 0 F Checked with local excavators„installers-(attacb�� — d USGS database-e.Viain: You descrilbe.how h ou established the high ground water elev H �a � � y0 _ shoe: i .s / f ��" e vie— it or r J w �o - S L-O CAT'ION SEWAGE PERMIT NO. " V LLAGE 9 0 14 wc, A(s-rliz /cH.Z14 IN TA LLER'S NAME i ADDRESS /f L �►,� 1 B. UILDER OR OWNER 3 q `f p , 13l+ III DATE PERMIT ISSUED DAT E COMPLIANCE ISSUED -;z 0 L- _ �, ���. ,� 3 q.,3 � �� b� F o/ No-6 Fizz... ...................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ......................... -" .-- ---.....OF...................................................... ApplirFatiun for Ropuual Worko Tonutrur#inn Frrutit Application is hereby made for a Permit to Construct ( ) or Repair (>Q an Individual Sewage Disposal System at: Location-Address or Lot No WS6Al ...�'.����� �?�`�Lv�rsr-_��Ys1',���,v-154R .� •.•. .......................-F............ Owner Address Installer Address Type of Building Size Lot__/_02 .Q.12...Sq. feet �-, Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) a a Other—Type of Building /�rw No. of persons........ ............... Showers ( ) — Cafeteria ( ) d Other fixtures .a....Gll l_ _ ./_N .._..-1 A C fINE---- !4 1 4_1..:/ /TCHf 11! t'l��./F........ W Design Flow..:.........:...............................gallons per person per day. Total daily flow.--------------------•----------__------_---gallons. WSeptic Tank.—Liquid capacity...a....?gallons Length................ Width................ Diameter___,_......... Depth___.___._.. x Disposal Trench—N .. `.... Width.................... Total Length.................... Total leaching area______-----____-• -sq. ft. Seepage Pit No.......�____.---- Diameter..A .. ---- Depth below inlet......7.......... Total leaching area..................sq. ft. Z Other Distribution box ( O� Dosing tank ( ) Percolation Test Results Performed by................................ ---- Date........................................ aTest Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Gi, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a — - . Descriptionof Soil............. �'1e :_... nLrt. ...'..............•---••-----•......-------••-----••--....--- -••-•-----------•---•--•-- y-: V •----•- Wi�� w ti�� r ds � s rod t ----------------------------------------•---•-•------•---•---- ......- ..._..... tu U Nature of Repairs or Alter — wer when ap 'cabl _.: ______________ _ ________ _� ~ _ �� a .� �l__..�.. : •----•--•---•---• Agreement: ••- - The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITIZ- 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. Signd-- - - - - ----------•---- - --------- -Da'te--•---•----•-- • Date Application Approved By-••••;he . r- ... - / --1 �`�fi `- ------------ Date Application Disapproved for following reasons:-------•------•----------------•-------------------•---•-------------------•---•-----------•--•--•----•-•••••-- ........................................................................................................................................................................................................ Date PermitNo.......................................................... Issued-..................................................-... Date No-le. ...__....: FEs..........................._ rs''' THE COMMONWEALTH OF MASSACHUSETTS ' BOARD OF HEALTH .. . App, iration for Disposal vrk� Tonstrnriiun ramit Application.is.hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ----------------- Lac tion-Address or Lot No. Owner a -------- -- / .)/ 1 �! ? ' -'/.................................... ..0A,4 .................... Q ;v Installer Address Type of Building. Size Lot______J,451...................Sq. feet v IV Dwellin o. of Bedrooms._........./...............................Ex ansion Attic Garba e Grinder� g—` P ( ) g ( ) p, Other—Type of BuildingPY11P.14.1.Ve.L. No, of persons.......3.................. Showers ( ) - Cafeteria ( ) 3 Other fixtures WAS*/S.A J'sf-�F.....--....Z.,�_T-fv--. ------------------•-- W 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-N'6_-------------------- Diameter.................... Depth below inlet..................... Total leaching area..................sq. ft. Z 06her Distribution box ( ,o,►) Dosing tank'-( ) Percolation Test Results t Performed by ------------- --- ---------------- ••---------- Date Test Pit No. I..........:.....minutes per inch Depth of Test Pit.................... Depth to ground water........................ Fz, Test Pit No. 2................minutes per inch Depth of Test Pit....... ------------ Depth to ground Water........................ 0 Description of Soil...................................`N U ---.....--•-•••...•--------------••--•-----------------... ._.....::..---------...........---.....----•-----------•------•-•----•......................................................... W --••-----•--- •--------------- --------•••--•---------- ....-••--••--•--. •- U Nature,of.Repairs or Alterations--Answer when applicabl _.. _t7,V.,Vre ._.7/_0.._ +l'I_''T��"�f'' Y T PIP, Agreement: 1_ 7J � ' The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLL 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. Signd. ......... ............................................................. .......................... f S .e- -- Date Application APProved',BY 110 I - :_..._..__ ....... _7. r Date 1 APPlication Disapproved f 0 following reasons ............................................................................................................... ---------------- .. Date Pernit`No:.:..................... Issued.---:..::--------•--------•-••-•:.... Date ....................... T14E COMMONWEALTH OF MASSACHUSETTS BOARD O HEAL H ' ¢! M...........O F........... ........... ....................:.... �rrtifirtt#r of f�unt�li�anrr THI IS TO CERTIF , That the:Individual .Sewage Disposal System constructed ( /�/or Repaired ( ) by -" ...'................. ------------ •. ---------•-------------------------------•--•--.._..-- p Installer -------- •-1t--------------•--------•- has been insta ed in accordance with the provisions of T r j of Toe State Sanitary C de a d scr e in the application for DisposaYWorks Construction Permit No.._�....7. --------.. tdated---------�-- ' 0------------------------ •-------• THE ISSUANCE`OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.. `-----------------•-- ...................:.. --•-------- Inspector -: f a THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH C ..... .............OF........... .............................................. 717) Of 'No................ ...... FEE..... ...- .... t' vrtt nrk� "trin rrntit Permissioni reby granted....... .. .- ..................•-•-------...---•--....._•-----.............-----..._.. to Construct ( oY Repair ( an ndi�tyge ispoml S,ystom at No.- ._. ado `" ti7T�✓.._ f! l/11�.--- '--' Street 7 as shown on the application for Disposal Works Construction Per o.:___-- _j--- lted..../�� ._._.t_�____..._.._1........... � . _ Board of Health DATE --•------------•--•............ ............................ FORM 1255 Hoses & WARREN, INC., PUBLISHERS - TOP OF FOUNDATION CONCRETE _ COVERS Zo IPISPECTION PORE 32 4."CASTIR' O � C[: 5w.30 ,�. SCHf1LE 40 4"SCHEDULE 40 P-V.C.(ONLY) r - P.V•C."i Mitt. PIPE - MIN. PITCH = Fiie�r z¢'Te CLEAN SAND BACKFILL s r .8' H t.4 PERFT: 1/.4"PER,FT. BE cwtG z :�; INVERT GASBAFFLE t, S INVERT INVERT r�= SEPTIC TANK s,;�, s;_ N J.3..Z s , �' tN wao GAL. EL .. - EL . . ./ EL 3 7dP• INVERT `DIST INVERT.✓ jM.1 EL S3�So.. BOX S i3 G.N.c� C EG ¢ a EL. .. ..... -...... ,vc.rY.. CHAMBERS PRO FI LE O F ADJ. GROUND WATER EL:��•_/.,Z SOIL LOG SEWAGE DISPOSAL SYSTEM T• ?',t# qc. TIME.. /B�* i4r1. NO SCALE _ DATE.... , 'PEST HOLE•.�..... TEST HOLE........ ELEV. � ... ELEV. ............ , VEGETATIVE COVER <=C• $,jo. DESIGN DATA : n 5 DPI Lm R NUMBER OF.BEDROOMS •: fiv6flMPi1 �c TOTAL; ESTIMATED FLOW .. .30.. ... GALLONS/DAY �6`, •¢B'Y�lc BWTOM 'LEACHING AREA �G��¢. SO.FT./TRENCH t7. /+VET s4i�w/> SIDE LEACHING AREA ... ' '.��... SOFT./TRENCH •r`'� /PYR %G GAR9AAs3f DISPOSAL••!�on/E.-(5O% AREA INCREASE) ��..3d 1rvT9G G /D" .. �t� Q�•.�Z,b� TOTAL LEAC1dINa at�A. . _ ....:• SQ.FT. LEACHING PERCOLATION RATE s'93/;�lti ¢H!•?!.. PER.INCH ................ jC•/Allis SAAKP � b � LEAOHING AREA PER PERCOLATION RATE..:..:...SO.FT�/l.,P)j• E /ayes:. ¢ ADJ.GROUND WATER WATER EI!NCi IN EREO. . W(TN'ESS�ED 8Y 37 1-2, � STj2¢s�-?- m r. T�1av o.. f BOAR®OF REALTtI ..........j QS ENGINEER �Q• _. ... ..... . ... .... . 8Q E0$� oQ �• •.AA07 R.P.L.S. PETITIONER : /�JGG/�!�/ W/f2Tjc}n!C_^al.. /� 19VEAL�p� J�//1 ZZ� Z oo .�Ci9LC �S 'q-0r&'D . El9WA21� �'. �fCEZc E 'FAG, l�i�� Ls,►�r� 5�,2VC}/a�e �3vX S/ ' G'C�r7hfi9Quty/ MA, 6L6-,�7 lit �-y A1o7E ELCl//�T A/ �LlEAN SEA L�✓GkL Al. ve of E. KELLEY No. 26100 'QECIST ER i d/ s/ANAL<Lt�MOS •gss�s'��►/zs M.qP r96 �.9�c�z 9 - ,.off•/q/ lire- i w OF _tAN % tl t IFr .�. , ,`���. !) :'�.,1. p�>� ` � fl �tgJ/y11p/ /w ,-` `• �. � J'Q '+.�/'1.��?.� j .~ � 1 QN -�N�� � t4 i i u ld zo/ y W-PM ea !S� 'Qe JO sh atAae i . TOP OF FOUNDATION 2 K /� � ► INSPECTION,v CONCRETE COVERS t2D. c toB, Zo Q t CG• PORT � / CUS 32 11, 4"CAST IRON 0 9 SCHEDULE 40 4 SCHEDULE 40 P.V,C.CONLY) _ tI P.V.C.PIPE MIN. PIPE - MIN. PITCH Fi2�r z¢„ro at PITCH t/4"PER.FT, 1/.4P PER,FT, c*sE cEVEc CLEAN SAND BACKFILL 1•Q�r 3 �m . . INVERT GAS BAFFLE _ .__ ..- INVERT e h i 3 EL,3 Se¢ SEPTIC TANK vEIZT 6 STONE a INVERT /vo Sa L/ EL 3 . .. P.... GAL. Q / .fit £L3`S98• INVERT DIET INVERT z �L, 6¢!Z S. 0 O J a EL._6...4...... BOX EL. 6 / ./fcl{ Cs+c.ry CHAMBERS E7ClS J'7^/G ,SC-,oT,c i LoGU 3 O-tFi P so*e- - / L000 ,7 a -1 PROFILE OF 1 _ a 64-L • ADJ. GROUND WATER EL'a9 fz - SEWAGE DISPOSAL SYSTEM SOIL LOG DATE.Tan/ zL Zoo¢ TIME /o.oo A� NO SCALE .... TEST HOLE / TEST HOLE t ELEV. `Sa'��„ ELEV. VEGETATIVE COVER 1 �szisr s „ DESIGN DATA : - �ee7vy27 NUMBER OF BEDROOMS 3. ... . aro fnvE'S*W0.57t�S TOTAL ESTIMATED FLOW •�`1�.. . GALLONS/DAY �' j� `. �• "' -.•�.... .. . Z�w �G..fSL.oB Y�� BOTTOM LEACHING AREA...��Y....... SO.FT./TRENCH ? per- r.. F/,W&^ SR�b SIDE LEACHING AREA ... . ..... ..... SO.FT./TRENCH loy2 7G �t�n/E 1 �4 I zr/O" I z4 � GARBAGE DISPOSAL.... .....I50 /o AREA INCREASE) r ��-� �-rt-•� TOTAL LEACHING AREA SO.FT. Z 7z •Sz.og LFs 7zr4n/s<rvr✓. LEACHING .r2�u�fs ' P17`S PERCOLATION RATE ..... . . ... ... PER.INCH 2.P� ,C/..lG�'3Aa� LEACHING AREA PER PERCOLATION RATE -3G /SSO.fT 'rv"D Ct /eY�G /G.R D. 49.tz J\ ,�,yG ADJ.GROUND WATER EL........... >r1 Y/ G } �/Gd 3 / .........WATER ENCOUNTEREQ O Q- y , ` I WITNESSED EY. 3 Gv.�/ ST2G�T I ?7.avfrJ ,�T.9r/7't�w u1�S T lzN r /3L c c 4,. _' .• .:...... .... .. .............. ..80A HEALTH .... .._ ..... .. ... .... � _ 0 ; + , i S At 2 .9LL /2 ors s, P . .... ...........>.......... ... .. ENGINEER . ....: . . .._ _..... EDS 1 I CDHr�2t� �. t` tG/a!� z s EVALA) 1. �..�.� r.2.Ia S ��' /' N _ PETITIONER —517 N _ Cam. t f 1 .,. `. , / . 14 / \ �1 �- ♦ N � .S L O r C G S e'D t , It -' 1 :,. r �_ s i ,fir eG-C. A/2c�F ��arD :5ti2✓- o� 7 . - - ' { o +:. c •. � ,§ Cl✓HN1/gQ Ul D /yi9, 6 ZG.3f' vo PAP' 7Zsl/ u� I / MEAN .SEA LE✓�L L-?jW/51/Z1a o � r X i # 1 SIR sc•� ��- A- o F� /71 •, t/C ° ; �1,, 0 OF bt-17 \ I i I DN/M. . E. S KELLEY 9 No. 26100 9ECIST5 S ,' �c, /ANAL LAMS I