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Home My WebLink About0010 SCORTON HILL ROAD - Health 10 Scorton HiIU Road ' 4 , W. Barnstable ': p .. A = 111 022 I h II� i� t.. i No. 4210 1/3 BLU r . 10% © C 0 0 Massachusetts Department of Environmental Protection Bureau of Resource Protection Well Completion Reports Well Driller t+ Please specify work performed: Address at well location: New Well Street Number: Street Name: 10 SCORTON HILL (til,8 Please specify well type: Building Lot#: Assessor's Map#: Domestic �� 111 Assessor's Lot#: ZIP Code: Number Of Wells: 022 02601 Cityrrown: Well Location BARNSTABLE In public right-of-way: GPS r' Yes (7 No North: West: 41.72493 70.39597 Subdivision/Property/Description: Mailing Address: click here if same as well location address ___............_..__..____---._.............._.._._...._._......__....._...........__..._.............................. Property Owner: Street Number: Street Name: CLAYTON CONN 10 SCORTON HILL City/Town: State: Engineering Firm: BARNSTABLE MASSACHUSETTS ZIP Code: 02601 Board of health permit obtained: r Yes t`_Not Required Permit Number: Date Issued: W2020025 I0L._.8/05/2020......_...__......................_...................._.__.... . Massachusetts Department of Environmental Protection Bureau of Resource Protection—Well Driller Program 4 �. Well Completion Re orts General t LI p A. ( ) i Well Driller - General Well Form DRILLING METHOD Overburderi' Bedrock huger Choose Bedrock WELLLOG OVERBURDEN LITHOLOGY 1 Drop in drill 1 Extra fast or slow Loss or addition From(ft) ITo(ft) Code +Color Comment I i stem !drill rate of fluid �0 i 20 Medium Sand 1 Brown Fast("Slow l YES NO I: _-_ __ Loss Addition +! r r ! 20 �j 30 �S!Ity Sand ll'Brown 1 YES NO 1,! ('Fast(Slow Loss Addition I YES..,NO,.......j;r--___� Loss Addition 30 ; 50 Clay , ; Light Gray Fast(�Slow I ................... f" f" ! .. _ Sl i T C e S Fast r r [Fine o oars �; Brown 1. I" ow l ._ � YES NO '' Loss Addition I : WELL LOG BEDROCK LITHOLOGY ......_...._......__._. ............................................................................................i Loss or Extra l ! Drop in !Extra fast or Visible Rust From(ft) 1 To(ft) Code !Comment addition of i Large 1 drill stem ;!slow drill rate Staining i fluid Chips L - I HT7 Yes' I YES NO :{ Fast Slow ELo Addition {------ Yes, 'r ! ADDITIONAL WELL INFORMATION Developed (''Yes —No Disinfected t:Yes t"No ---------------- Total Well Depth 60 Depth to Bedrock Surface Sea!Type None racture Enhancement "Yes f�No CASING 7 Is Casing above From: 1 To: 0 From To Type Thickness Diameter Driveshoe �0 �56 f Polyvinyl Chloride Schedule 404 Yes ................._.................._. SCREEN+r No Screen From To Type Slot Size i Diameter ! i 56 Stainless Steel WeII Point j0 012 i 4 WATER-BEARING ZONES !DRY WELL; Frog m To Yield(gpm) 15 60 12- _ __1 PERMANENT PUMP(IF AVAILABLE) 2 Wire Constant Spe ed Pump Description Horsepower Submersible 3/ Massachusetts Department of Environmental Protection L Bureau of Resource Protection—Well Driller Program Well Completion Reports(General) ) Pump Intake Depth(ft) 55 Nominal Pump Capacity(gpm) 10 ANNULAR SEAL'FILTER PACK ------------------..__..-_________________._____..__......____..___......__,....__-__.------_-------_ ___--..... .__.-..___..-..--_--------...-_-..-___.._------------._......._____ __.._-__--__......_ ___-__ Water )Batches Method Of From !To Material 1 Weight Material 2 Weight ht (gal) I(coun�t")""� Placement 'Choose Material �� Choose Material 1 i"Choose One -----------..................___.._.__._______.--------- . ______ _._ --------v_..___.___.__-- ------ ______.._..t.:................................................................ WELL TEST DATA Date Method Yield(gpm) Time Pumped Pumping Level(ft 'Time To Recover Recovery(ft (HH:MM) BGS) (HH:MM) BGS) 09I11I2020 Constant Rate Pump 12 1:30�� '11� '0001 15 I �m�....._.....mm f WATER LEVEL I Date Static Depth BGS(ft) Flowing Rate(gpm) Measured 09/11/2020 15 COMMENTS WELL DRILLERS STATEMENT This well was drilled or altered under my direct supervision,according to the applicable rules and regulations,and this report is complete and accurate to the best of my knowledge. WILLIAM Supervising Driller DESMOND, DrillerURQUHART Registration# 299 Monitoring[M] Signature THOMAS,E DESMOND WELL Firm DRILLING,INC. Rig Permit#. . 0551 Date Job Complete 09-24/202C NOTE:Well Completion Reports must be filed by the registered well driller within 30 days of well completion. ENVIROTEC'H,tABORATORtES, INC; .HA CERT. NO.:.MC-MA 063 8.Jnn Sehnstian>13ri�e.1/irit I2 Sa,ndwicli, DfA 02543 (500088-6460 7-800-339;6460 FAX(50.4)8884446. Client Nanie; Desmond TV611 Drilling L.00ttliO/t I .Address: PO Box 2.783 10 Scorton Hill Rd Orleans, MA W Barnstable,MA 02653 .LOb.Naniber DW-203400 Collected By DWD Date Received:..: 09/151/20 Strt>zRle Type..,. W€USj1eCS New Well 60'/1.5' ..... -. <SCvtnmerttS4 AnaCysis:Requesteii units. Recommended LrnM& Anaiysls Rrsg t Mrlhod Dtrta Analyzed An niyeerl B Total Coliform CFU1100mL 0..... 0 SM9222B 09/16/2020 KF @ 13:00 W..__ .... _.._ ....._.. pH pH units 6 5 8.5 6.35 SM 4500-H-B 09/15/2020 .. SD j _ - ._.... ..... _ _... ..._.... ... Specific Conductance« u:mhos/crb 500 176 EPA 120.1 09/15/2020 SD Nitrite N mg1L 1.00 .50.00.6 EPA 300.0 09/16/2020 LL ... ...._._ ....... Nitrate N mg/L 10.0 2,20 EPA_300.0 09/16/2020 LL Sodium mg/L ._......... 20 0' 19 EPA 200.7 09/21/2020 KB - .. Total Iron mg/L 0 3 0.06 EPA 200 7 09/21/2020 k6 .__..._.. .,:._.._. .�.,.Man'gah2se�.�,.�_ �.,. _,�._.m91L �:,�,____;_r___0:0`5`-,�.�._,, �...0.005_._.__�EPA200,7 09/21/2020 KB ....... ..__. ..._ . .... ,... ......— M.� _._ ...... -__.__ Volatile Organic Compounds' ug/L See.comment. "See,Attached EPA 524.2 09/17/2026 NEC* Comments; pH,is below recommended limit and may have corrosiv&characteristics. Chloroform,and three other trihalomethanes(THMs)—bromodiehtorometha.ne,dibromochloromethane,and bromoform,—are disinfection by-products commonly produced during the chlorination of water. All samples were analyzed within the established guidelines of US EPA approved methods with:alf requirements m.et;. unless otherwise noted at the end of a given sample's analytical results. We.certify that the following results are true and accurate to the best of our knowledge. Water meets EPA standards and is suitable for drinking for parameters tested. Date 9/2212020 Rdnnld J SdaH Ln4014 DiNctor .BRL Relou!Reportable.Limits *See Attached Page 1 of 1 oC61ificaiion.is)wt available for Ibis analyle forpotable»pater samples.: No. "() Fee BOARD OF HEALTH Z� TOWN OF BARNSTABLE 2pprication jFor Yell Construction Permit Application is hereby made for a permit to Construct(4, Alter( ), or Repair( ) an individual well at: 10 S CZAD-n )Ail\ PA .W &Cr��IIL 1 oz2 Location-Address'^ Assessors Map and Parcel - C nh)n 10 scotAyn"Ak �A Aj$ardot� MA oast Owner Address ��► �� c��i ��r�. �P-o�o� Z��3, Q�l�r-s YYY� 42b6$ Installer-Driller Address Type of Building Dwelling Other-Type of Building No. of Persons Type of Well ) " S cA 40 VC— '""WtT44 Capacity JO i1i�`^ Purpose of Well ?aWCLL &tok S01W L 10WA10y' Agreement: The undersigned agrees to install the afore described individual well in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation-The undersigned further agrees not to place the well in operation until a Certi c e o Co pliance has been issued by the Board of Health. Signed w 3l � Date' Application Approved By � Date Application Disapproved for the following reasons: Date Permit No. ��e�'J Issued Date OF RD TOWN 0FABARTNSTABLE j Certificate of Compliance i THIS IS TO CERTIFY that the individual well Constructed X, Altered or Repaired( by 1\ jy\Q 1nL Installer at 10 sc ocNo-r-, iA 1�� Ra , has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Froteation Regulation as described in the application for Well Construction Permit NalfD -12� S Dated THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORILY. Date Inspector No.'s dos Fee BOARD OF HEALTH TOWN OF BARNSTABLE ZIPPrication -for Yell Construction permit Application is hereby made for a permit to Construct Op), Alter( ), or Repair( ) an individual well at: ' Locatio0Address Assessors Map and Parcel nan S to S cot A b n 1A;Il �d )N-k mtrlts. llliA QZ4Z Owner Address Nw, hl QZG6'b Installer-Driller Address Type of Building e _. , Dwelling � .. - ... - __ _ ---Other---Type of Building No. of Persons Type of Well ' S QAH0 VC- "C�(L Capacity Purpose of Well ?DWC' L Agreement: The undersigned agrees to install the afore described individual well in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation-The undersigned further agrees not to place the well in operation until a Certi c ate o,fCompliance has been issued by the Board of Health. Signed (j -�I r Date Application Approved By Date Application Disapproved for the following reasons: Date Permit No. Issued Date BOARD OF HEALTH TOWN OF BARNSTABLE Certificate of Compliance THIS IS TO CERTIFY,that the individual well Constructed.k), Altered( ), or Repaired( ) by 1 eS»rno,rv, \NQ 1\ ,\hL } Installer at O S CoC�t�Y� 1 �� o rykorx,o u- 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,j Z —Q�S Dated S =)-d THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORILY. Date Inspector BOARD OF HEALTH TOWN OF BARNSTABLE Vern Con6truction 3permtt Fee Permission is hereby granted to ¢ Installer to Construct( i, `Atlter( ), \or . Repair( an individual well at: No. `0 C C t�C�nYI f�l �, RN) Street J as shown on the application for a Well Construction Permit No.J�)` '� J ��s Dated Date /.�/ Approved By C2 M- . . . :. Legend Road Names Sp 9Wnow r r a. Y V ,, . lk � 4 _ J x � k i b I _ ' Map printed on: 7/27/2020 This map is for illustration purposes only.It is not Parcel lines shown on this map are only graphic Town of Barnstable GIS Unit adequate for legal boundary determination or representations of Assessor's tax parcels.They are Feet regulatory interpretation.This map does not represent not true property boundaries and do not represent 367 Main Street,Hyannis,MA 02601 O 42 83 an on-the-ground survey.It may be generalized,may not accurate relationships to physical objects on the map 5o8-862-4624 reflect current conditions,and may contain such as building locations. Approx.Scale: I inch= 42 feet 0 cartographic errors or omissions. gis@town.barnstable.ma.us Asse4ingTAs-Built Cards 7/27/20,8:16 AM TOWN 1OF BARNSTABLE LOCATON ID SCOAalrr Nr1l SEWAGE# VILLAGE W. f�11fn STpb� ASSESSOR'S MAP 8c LOT/t 1 Oaf INSTALLER'S NAME dt PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY:(type) e 6 & P (size) �� (5AI. NO.OFBEDROOMS 3 BUILDER OR.OWNER 6 f 1/ SCArt-)/1 t 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 —J--- s5—4, J ^ Si e- A` A(- 19 at 81- 3a A&- S0 H a ��- 133- 1r A"4- Y3 3 13y- (#(a https://townofbarnstable.us/Departments/Assessing/Property_Values/HMdisplay.asp?mappar=111022&seq=1 Page 1 of 2 CERTIFICATE OF ANALYSIS Page: 1 0 Barnstable County Health Laboratory 9rstc�3�5` Report Prepared For: Report Dated: 7/2/2008 Tara Brown Q, Bayview Real Estate `P Order No.: G0847343 P O Box 165 t Barnstable, MA 02630 Laboratory ID#: 0847343-01 Description: Water-Dri a er I Sample#: Sampling Loco ' n: I Scornton Hill Rd.West Barnstable,MA Collected: 6/30/2008 Collected by: T.S.Brown Received: 6/30/2008 Routine ITEM RESULT UNITS RL MCL Method# Analyst Tested Note Nitrate as Nitrogen: 0.97 mg/L 0.10 10 EPA 300.0 LAP 6/30/2008 Copper ND mg/L 0.10 1.3 SM 311113 LAP 7/l/2008 Iron ND mg/L 0.10 0.3 SM 3111B LAP 7/I/2008 Sodium 15 mg/L 1.0 20 SM 3111B LAP 7/l/2008 Total Coliform Absent P/A 0 0 SM9223 AF 6/30/2008 Conductance 140 umohs/cm 2.0 EPA 120.1 DCB 6/30/2008 6.6 pH-units 0 SM 4500 H-B DCB 6/30/2008 Water sample meets the recommended limits for drinking water of all the above tested parameters. _... -----—.....--------- —----- ---- ----- — -- ------- 6� Approved By• (Lab erector) ND None Detected RL Reporting ingLimit MCL— Maximum Contaminant Level Superior Court House, PO. Box 427, Barnstable, MA 02630 Ph: 505-375-6605 ' Commonwealth of Massachusetts C-v�+ Title 5 Official Inspection Form Subsurface Sewage Disposal System form-Not for Voluntary Assessments �� 10 Scorton Hill Road Property Address ' t 1 Richard Bean Owner Owner's Name information is required for West Barnstable MA 02668 07/03/08 every 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. Important:When filling out A. General Information - forms on the computer,use � only the tab key 1. Inspector: ,. to move your Michael Kellett cursor-do not Name of Inspector use the return key. Aardvark Environmental Inspections Company Name C) M P.O. Box 896 Company Address East Dennis MA 02641 City/Town State Zip Code 508-385-7608 S13742 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 16.340 of Title 5(310 CMR 16.000).The system: - ® Passes ❑ Conditionally Passes ❑ Fails. . ❑ Needs Further Evaluation by the Local Approving Authority j 07/06/08 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system 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. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 10 Scorton Hill Road Property Address Richard Bean Owner Owner's Name information is west Barnstable MA 02668 07/03/08 required for Date of Inspection q Cityfrown State Zip Code p every page. B. Certification (cont.) Inspection Summary:Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: 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. Answer yes, no or not determined(Y, N, ND)in the ❑for the following statements. If"not determined," please explain. ❑ The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. 'A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ obstruction is removed f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 10 Scorton Hill Road Property Address Richard Bean Owner Owner's Name information is West Barnstable MA 02668 07/03/08 required for State Zip Code Date of tnspecdion every page. Cityrrown B. Certification (cont.) B) System Conditionally Passes(cunt.): ❑ 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: C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �t 10 Scorton Hill Road Property Address Richard Bean Owner Owner's Name information is West Barnstable MA 02668 07/03/08 required for State Zip Code Date of Inspection every page. City/Town B. Certification (cont.) C) Further Evaluation is Required by the Board of Health(cont.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than %day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® 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. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage.Disposal System Form-Not for Voluntary Assessments 10 Scorton Hill Road Property Address Richard Bean Owner Owner's Name information is West Barnstable MA 02668 07/03/08 required for State Zip Code Date of Inspection every page. City/Town B. Certification (cunt.) D) System Failure Criteria Applicable to All Systems(cont.): Yes No ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 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 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 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. 7 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ,,. 10 Scorton Hill Road Property Address Richard Bean Owner Owner's Name information is West Barnstable MA 02668 07/03/08 required for Cityrrown State Zip Code Date of inspection every page. 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? El ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® El information 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)] Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 10 Scorton Hill Road Property Address Richard Bean Owner Owner's Name information is required for WeSt Barnstable MA 02668 07/03/08 every page. City/Town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?(if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No u ❑ Yes ® No Seasonale.s Water meter readings, if available(last 2 years usage(gpd)): Sump pump? ❑ Yes ® No Last date of occupancy: current 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: Last date of occupancy/use: Date Other(describe): Commonwealth of Massachusetts Tale 5 Official Inspection ection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments < 10 Scorton Hill Road Property Address Richard Bean Owner Owner's Name information is West Barnstable MA 02668 07/03/08 required for CityRown State Zip Code Date of Inspection every page. D. System Information (cont.) General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes,volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system [] Single cesspool ❑ Overflow cesspool [] Privy ❑ Shared system(yes or no)(if yes, attach previous inspection records, if any) Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: 5/2/89 per,BOH Were sewage odors detected when arriving at the site? ❑ Yes ® No t. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 10 Scorton Hill Road Property Address Richard Bean Owner Owner's Name information is required for West Barnstable MA 02668 07/03/08 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): 3.4 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): 2.8 _ Depth below grade: feet Material of construction: ®concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No -------------------------------------------------------------------------------------------------- Dimensions: - - -- --- - - 1000 gallons 3" Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 29" 2-1Scum thickness Distance from top of scum to top of outlet tee or baffle 8" Distance from bottom of scum to bottom of outlet tee or baffle 15" How were dimensions determined? measured Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments `Y 10 Scorton Hill Road Property Address Richard Bean Owner Owner's Name information is West Barnstable MA 02668 07/03/08 required for CitylTown State Zip Code Date of Inspection every page. 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.): The tank was sound and tight with tees in place and liquid at outlet invert. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 10 Scorton Hill Road Property Address Richard Bean Owner Owner's Name information is West Barnstable MA 02668 07/03/08 required for State Zip Code Date of Inspection every page. Citylrown D. System Information (cont.) Tight or Holding Tank(cunt.) 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 Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert even Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover, any evidence of leakage into or out of box, etc.): The box was level and tight with no sign of carryover. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 10 Scorton Hill Road Property Address Richard Bean Owner Owner's Name information is West Barnstable MA 02668 07/03/08 required for CitylTown State Zip Code Date of Inspection every page. D. System Information (cont.) Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System(SAS)(locate on site plan, excavation not required): If SAS not located, explain why: Type: 2 ® leaching pits number: ❑ leaching chambers number: ❑ 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.): This system has two 6'x6' precast pit surrounded by 2'of stone. There was no sign of ponding or failure. f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 10 Scorton Hill Road Property Address Richard Bean Owner Owner's Name information is West Barnstable MA 02668 07/03/08 required for State Zip Code Date of Inspection every page. Cityfrown D. System Information (cont.) Cesspools(cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposals System Form-Not for Voluntary Assessments 10 Scorton Hill Road Property Address Richard Bean Owner Owner's Name information is West Barnstable MA 02668 07/03/08 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. �1 3 � � 7 b6 � Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 10 Scorton Hill Road Property Address Richard Bean Owner Owner's Name Information is West Barnstable MA 02668 07/03/08 required for State Zip Code Date of Inspection every page. Cityrrown D. System Information (cont.) Site Exam: Z Check Slope ❑ Surface water Check cellar ❑ Shallow wells 25 Estimated depth to ground water: feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: You must describe how you established the high ground water elevation: USGS maps show an elevation of over 25'. Town of Barnstable FIRE 1py� "o Regulatory Services BARMSTABLE,~* Thomas F. Geiler,Director y MASS. `6 039. 6.�• Public Health Division ACED MA'S Thomas McKean,Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 REGARDING SEPTIC INSPECTIONS BY PRIVATE CONTRACTORS DISCLAIMER This septic system inspection report was completed by a private inspector who is certified by the State of Massachusetts, Department of Environmental Protection. Although the Town of Barnstable Health Division received the original or copy of the report; this Division does not warranty the functionality of the septic system in the future nor does this Division agree with any technical observations and interpretations contained within this report. In addition, by receiving this report the Town of Barnstable Health Division does not automatically approve the number of bedrooms listed within this report. The actual number of bedrooms approved at a particular property would be listed on the "Disposal Works Construction Permit". If you should have any questions regarding this report, please contact the certified Septic System Inspector who conducted the inspection. QASEPTIC\Disclaimer Private Septic Inspections.DOC ®y v w COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARK SUBSURFACE SEWAGE DISPOSAL SYSTEM FO PART A MAY 2 9 2002 CERTIFICATION TOWN OF BARNSTABLE Property Address: 10 Scorton Hill Road HEALTH DEPT. West Barnstable, MA 02668 Owner's Name: Bill&Nancy Schreiner z 4:1 Owner's Address: 3 Wintergreen Lane Sandwich, MA 02563 Date of Inspection: May 15, 2002 Name of Inspector: (Please Print) James M. Ford Company Name: James M. Ford Map: III Mailing Address: P.D. Box 49 Parcel: 022 Osterville, MA 02655-0049 Telephone Number: (508) 862-9400 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 Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fai f Inspector's Signature: Date: May 20, 2002 The system inspector shall sub 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 ****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. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 10 Scorton Hill Road West Barnstable, MA Owner: Bill&Nancy Schreiner Date of Inspection: May 15, 2002 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: ✓ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: 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. 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 infil.ration 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 thaa 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: 2 Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 10 Scorton Hill Road West Barnstable, MA Owner: Bill&Nancy Schreiner Date of Inspection: May 15, 2002 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment, 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. :System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. 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: 3 Page 4 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 10 Scorton Hill Road West Barnstable, MA Owner: Bill&Nancy Schreiner Date of Inspection: May 15, 2002 D. System Failure Criteria applicable to all systems: You must indicate either"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 '/2 day flow ✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_. ✓ 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 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. 1 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 System: 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 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. 4 Page 5 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 10 Scorton Hill Road West Barnstable, MA Owner: Bill&Nancy Schreiner Date of Inspection: Mav 15, 2002 Check if the following have been done: You must indicate`yes"or"no"as to each of the following: Yes No ✓ Pumping information was provided by the owner, occupant,or Board of Health ✓ Were any of the system components pumped out in the previous two weeks? ✓ Has the system received normal flows in the previous two week period? ✓ Have large volumes of water been introduced to the system recently or as part of this inspection ? ✓ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ✓ Was the facility or dwelling inspected for signs of sewage back up? ✓ Was the site inspected for signs of break out? ✓ Were all system components,excluding the SAS, located on site? ✓ _ Were the septic tank manholes uncovered, opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid, depth of sludge and depth of scum ? ✓ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes No ✓ 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(3)(b)]. 5 Page 6 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 10 Scorton Hill Road West Barnstable, MA Owner: Bill&Nancy Schreiner Date of Inspection: May 15, 2002 FLOW CONDITIONS RESIDENTIAL. Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 0 Does residence have a garbage grinder(yes or no): Yes 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)): Private well Sump Pump(yes or no): No Last date of occupancy: Unknown COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 1.5.203): 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: Pumped on Jul. 27198-per treatment plant Was system pumped as part of the inspection (yes or no): No If yes,volume pumped: Qallons-- How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM ✓ Septic tank, distribution box, soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no (if yes, attach previous inspection records, if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight Tank Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: New pit added May 2189-per as built card Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 10 Scorton Hill Road West Barnstable, MA Owner: Bill&Nancy Schreiner Date of Inspection: May 15, 2002 BUILDING SEWER(locate on site plan) Depth below grade: Approx. 4' Materials of construction: _cast iron ✓ 40 PVC _other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting, evidence of leakage, etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 36" Material of construction: ✓ 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 gal. Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: 10" Distance from top of scum to top of outlet tee or baffle: 10" Distance from bottom of scum to bottom of outlet tee or baffle: 5" How were dimensions determined: Measuring stick Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert, evidence of leakage,etc.): Tees were present. The liquid level was even with the outlet invert. There were no signs of leakage. Recommend pumping. GREASE TRAP: None (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.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 10 Scorton Hill Road West Barnstable, MA Owner: Bill&Nancy Schreiner Date of Inspection: May 15, 2002 TIGHT or HOLDING TANK: None (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: ✓ (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Even Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover,any evidence of leakage into or out of box, etc.): The D-box was level. Sludge was present. Recommend cleaning the D-box when the septic tank is pumped. PUMP CHAMBER: None (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.): 8 Page 9 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 10 Scorton Hill Road West Barnstable, MA Owner: Bill&Nancy Schreiner Date of Inspection: May 15, 2002 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type ✓ leaching pits,number: 2- 6'x 6'- 1000 gal. leaching chambers,number: 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.): One pit(93)had 6"of water on the bottom. The scum line was approximately T up from the bottom. The bottom to grade was approximateiy 9' The cover was 10"below grade. The other pit 04)had 4'of water on the bottom. The scum line was at the same level The bottom to grade was 10'and the cover was 20"below grade. There were no signs of failure. CESSPOOLS: None (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.): PRIVY: None (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.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 10 Scorton Hill Road West Barnstable, AM Owner: Bill&Nancy Schreiner Date of Inspection: May 15, 2002 Map: I I I Parcel: 022 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. SI 2 Ai - 19 ac 81 - 3a Aa- So 13a- S 143 10 1 ` Page 11 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 10 Scorton Hill Road West Barnstable, MA Owner: Bill&Nancy Schreiner Date of Inspection: May 15, 2002 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water feet Please indicate (check) all methods used to determine the high ground water elevation: 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: topographic and water contours maps Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: _The bottom of the leach pit to grade was approximately 10' Using the Barnstable topographic map and the Cape Cod Commission water contours map the maps were showing approximately 30'+/-to ground water at this site. This report has been prepared and the system inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed, written or implied, relating to the system, the inspection and/or this report. y 11 I i I r RECEIVED J U N 1 4 2000 TOWN OF BARNSTABLE HEALTH DEPT. COMMONWEALTH OF MASACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAI AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET BOSTON MA 02108(617)292-3500 TRUDY CORE Secretary ARGEOPAULCELLUCCI DAVID B.STRUHS Govemor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 10 SCORTON HILL RD WEST BARNSTABLE, MA 02668 Name of Owner RUTH ALLEN Address of Owner: 10 SCORTON HILL RD WEST BARNSTABLE,MA 02668 Date of Inspection: 5/31/00 Name of Inspector: JOHN GRACI I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) Company Name: SEPTIC INSPECTIONS Mailing Address: P.O.BOX 2119 TEATICKET,MA.02636 Telephone Number: 608-664-6813 FAX 608-664-7270 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is truesacct�rate and complete as of the time of inspection.The inspection was performed based on my training and experience in the proper f�n lonland� f maintenance of on-site sewage disposal systems.The system: X Passes �(P/►,. ' Conditionally Passes _ Needs Further Evalua'on By the Local Approving Authority p Fails OAi�"sr 0000 Inspector's Signature: Date:611100, Nam' The System Inspector shall sub it a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(30)days of completing this inspection.If th 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 Department of Environmental Protection.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. NOTES AND COMMENTS "The inspection is based on criteria defined in Title V code 310 CMR 15.303.My findings are of how the system is performing at the time of inspection.My Inspection does not imply any warranty or guarantee of the longevity of the septic system and any of its components useful life." THE SYSTEM PASSES TITLE V INSPECTION.RECOMMEND PUMPING THE SYSTEM EVERY ONE TO TWO YEARS FOR PROPER MAINTENANCE. s revised 9/2198 Page 1 of 11 r I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 10 SCORTON HILL RD WEST BARNSTABLE, MA 02668 Name of Owner RUTH ALLEN Date of Inspection: 6131/00 INSPECTION SUMMARY: Check A, B, C, or D: A. SYSTEM PASSES: X I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist.Any failure criteria not evaluated are indicated below. 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. Indicate yes,no,or not determined(Y,N,or ND).Describe basis of determination in all Instances.If"not determined",explain why not. n/a The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or the septic tank,whether or not metal,Is cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank failure is imminent.The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. Wa Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box.The system will pass inspection if(with approval of the Board of Health). _broken pipe(s)are replaced _obstruction is removed _distribution box is levelled or replaced nLa The system required pumping more than four 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 .�E revised 9098 Page 2 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 10 SCORTON HILL RD WEST BARNSTABLE, MA 02668 Name of Owner RUTH ALLEN Date of Inspection: 6/31/00 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 the public health,safety and the environment. 1) SYSTEM WILL PASS UNLESSBOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT ThE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ Cesspool or privy is within 50 feet of 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 AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I of a public water supply well. _ The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well, The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis 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,Method used to determine distance n&(approximation not valid). 3) OTHER n/a revised 9/2/98 Page 3 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 10 SCORTON HILL RD WEST BARNSTABLE, MA 02668 Name of Owner RUTH ALLEN Date of Inspection: 6/31/00 D. SYSTEM FAILS: You must indicate either"Yes"or"No"to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303.The basis for this determination is identified below.The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No X Backup of sewage into facility or system component due to an 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 1/2 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 0. X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. X Any portion of a 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 I 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.If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E. LARGE SYSTEM FAILS: 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: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply X 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) The owner or operator of any such systemishall upgrade the system in accordance with 310 CMR 15.30412).Please consult the local regional office of the Department for further information. revised 9/2198 Page 4 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 10 SCORTON HILL RD WEST BARNSTABLE, MA 02668 Name of Owner: RUTH ALLEN Date of Inspection: 6/31100 Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following: Yes No _ Pumping information was provided by the owner,occupant,or Board of Health. X _ None of the system components have been pumped for at least two weeks and-the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. X As built plans have been obtained and examined.Note if they are not available with N/A. X _ The facility or dwelling was inspected for signs of sewage back-up. X _ The system does not receive non-sanitary or industrial waste flow. X _ The site was inspected for signs of breakout. X _ All system components,excluding the Soil Absorption System,have been located on the site. X _ The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum.The size and location of the Soil Absorption System on the site has been determined based on: _ Existing information,For example,Plan at B4O,H, _ Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable)1 5.302(3)(b)) X _ The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of SubSurface Disposal Systems. revised 9/2198 Page 5 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 10 SCORTON HILL RD WEST BARNSTABLE, MA 02668 Name of Owner RUTH ALLEN Date of Inspection: 6/31/00 FLOW CONDITIONS RFS113ENTIAL: Design flow: 110 g.p.d./bedroom Number of bedrooms(design): 4 Number of bedrooms(actual): Total DESIGN flow: 440 gpd Number of current residents:n/a Garbage grinder(yes or no):NO Laundry(separate 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 two year's usage): n/a gpd Sump Pump(yes or no): NO Last date of occupancy: 2/1100 COMMERCIALIINDUS RIAL Type of establishment: n/a Design flow: n/a gpd(Based on 15.203) Basis of design flow:n/a Grease trap present:(yes or no): NO Industrial Waste Holding Tank present:(yes or no): NO Non-sanitary waste discharged to the Title 5 system:(yes or no):NO Water meter readings.if available: n/a Last date of occupancy:n/a OTHER: (Describe) n/a GENERAL INFORMATION PUMPING RECORDS and source of information: n/a System pumped as part of inspection:(yes or no):NO If yes,volume pumped n/a gallons Reason for pumping:n/a TYPE OF SYSTEM X 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) _ I/A Technology etc.Attach copy of up to date operation and maintenance contract _ Tight Tank Copy of DEP Approval Other:n/a APPROXIMATE AGE of all components,date installed(if known)and source of information: 1979 Sewage odors detected when arriving at the site:(yes or no): NO revised 9/2198 Page 6 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 10 SCORTON HILL RD WEST BARNSTABLE, MA 02668 Name of Owner RUTH ALLEN Date of Inspection: 6/31100 BUILDING SEWER:X (Locate on site plan) Depth below grade: 64" Material of construction: _ cast iron X 40 Pvc _ other(explain) Distance from private water supply well or suction line: n/a Diameter: 4" Comments: (condition of joints,venting,.evidence of leakage,etc.) THE SYSTEM HAS TOWN WATER. SEPTIC TANK: X (locate on site plan) Depth below grade: 48" Material of construction: X concrete_ metal_ Fiberglass_ Polyethylene_ other explain: n/a If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): NO Age: n/a Dimensions: 1000G L 8'6"H 6'7"W 4'10"" Sludge depth: 3" Distance from top of sludge to bottom of outlet tee or baffle: 31" Scum thickness: 1" 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: n/a How dimensions were determined: MEASURED Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage, etc.) THE SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND.RECOMMEND PUMPING EVERY ONE YO TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE. GREASE TRAP: _ (locate on site plan) Depth below grade: n/a Material of construction: _concrete_ metal_ Fiberglass _ Polyethylene_other Explain: n/a Dimensions:n/a Scum thickness: n/a Distance from top of scum to top of outlet tee or baffle: n/a Distance from bottom of scum to bottom of outlet tee or baffle n/a Date of last pumping: n/a Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage, etc.) n/a 4 revised 9098 Page 7 of 11 e; SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 10 SCORTON HILL RD WEST BARNSTABLE, MA 02668 Name of Owner RUTH ALLEN Date of Inspection: 6/31100 TIGHT OR HOLDING TANK: _ (Tank must be pumped prior to,or at time of,inspection) (locate on site plan) Depth below grade: n/a Material of construction: _concrete_ metal_Fiberglass _Polyethylene _other Explain: n/a Dimensions: n/a Capacity: n/a gallons Design flow: n/a gallonstday Alarm present: NO Alarm level:NIA Alarm in working order:NO Date of previous pumping: n/a Comments: (condition of inlet tee,condition of alarm and float switches,etc.) n/a DISTRIBUTION BOX:_ (locate on site plan) Phis Depth of liquid level above outlet invert: nla Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) n/a PUMP CHAMBER: _ (locate on site plan) Pumps in working order.(Yes or No): NO Alarms In working order(Yes or No): NO Comments: (note condition of pump chamber,condition of pumps and appurtenances.etc.) n/a yr,k revised 9098 Page 8 of 11 • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM h PART C SYSTEM INFORMATION(continued) Property Address: 10 SCORTON HILL RD WEST BARNSTABLE, MA 02668 Name of Owner RUTH ALLEN Date of Inspection: 6/31100 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods) If not located,explain: n/a Type: leaching pits,number:(1)1000 GAL li X 6 leaching chambers,number: (n/a)n/a leaching galleries,number: (n/a)n/a leaching trenches,number,length: (n/a)n/a leaching fields,number,dimensions: (n/a)n/a overflow cesspool,number: (n/a)n/a Alternative system: n/a Name of Technology: n/a Comments: (note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) THE LEACH PIT IS STRUCTURALLY SOUND AND APPEARS TO BE FUNCTIONING PROPERLY.THE PIT HAD 2'OF LEACHING LEFT AT THE TIME OF THE INSPECTION. CESSPOOLS: _ (locate on site plan) Number and configuration: n/a Depth-top of liquid to inlet invert: n/a Depth of solids layer: n/a Depth of scum layer. n/a Dimensions of cesspool: n/a Materials of construction: n/a Indication of groundwater: n/a inflow(cesspool must be pumped as part of inspection)NO Comments: (note condition of soil,signs of hydraulic,failure,level of ponding,condition of vegetation,etc.) n/a PRIVY: (locate on site plan) Materials of construction: n/a Dimensions: n/a Depth of solids: n/a Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) n/a revised 9/2/98 Page 9 of 11 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 10 SCORTON HILL RD WEST BARNSTABLE, MA 02668 Name of Owner RUTH ALLEN Date of Inspection: 6/31/00 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes into house) 6 A ��y g ;o W1 31 revised 9/2/98 Page 10 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 10 SCORTON HILL RD WEST BARNSTABLE, MA 02668 Name of Owner RUTH ALLEN Date of Inspection: 6/31/00 NRCS Report name: n/a Soil Type: n/a Typical depth to groundwater: n/a USGS Date website visited: n/a Observation Wells checked: NO Groundwater depth: Shallow_ Moderate_ Deep_ SITE EXAM _ Slope _ Surface water _ Check Cellar Shallow wells Estimated Depth to Groundwater 12 Feet+ Please indicate all the methods used to determine High Groundwater Elevation: _ Obtained from Design Plans on record _ Observed Site(Abutting property,observation hole,basement sump etc.) Determined from local conditions Checked with local Board of health Checked FEMA Maps Checked pumping records Checked local excavators,installers X Used USGS Data u Describe how you established the High Groundwater Elevation.(Must be completed) USGS MAPS AND CHARTS-12+FEET revised 9/2/98 Page 11 of 11 CERTIFICATE OF ANALYSIS Page: 1 Barnstable County Health Laboratory Report Prepared For: Report Dated: 07/19/2000 Order Number: G0006717 Beverly Comeau 133 Route 6A Sandwich, MA 02563 Laboratory ID#: 0006717-01 Description: Water-Drinking Water Sample#: 06717 Sampling Location: 10 Scorton Hill Rd.,West Barnstable Collected: 07/12/2000 ollected by: Beverly Come 111-022 Received: 07/12/2000 Routine ITEM RESULT UNITS MCL Method# Tested LAB:IC Lab Nitrates 0.7 mg/L 10 EPA 300.0 07/12/2000 LAB:Metals Copper 0.1 m.-/L 1.3 SM 311113 07/13/2000 Iron <0.1 m.�/L 0.3 SM 311113 07/13/2000 Sodium 14 mg/L 20 SM 311113 07/13/2000 LAB: Microbiology Total Coliform Present _ NA Absent P/A 07/12/2000 LAB: Physical Chemistry Conductance 136 umohs/cm EPA 120.1 07/12/2000 pH 6.5 pH-units EPA 150.1 07/12/2000 Note: Exceeds the recommended maximum contamination level for drinking water due to presence of Coliform Bacteria. Approved By: (Lab Director) Superior Court House, PO.Box 427, Barnstable, MA 02630 Ph: 508-375-6605 TOWN OF ARNST A IRLE .O � � L J ► SEWAGE # W� LAGE. ASSESSOR'S MAP & LO4 ' INSTALLER'S NAME&PHONE NO. i SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO. OF BEDROOMS BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: <�tt' �C— t( � 1 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 lo' TO=] { a0 AA 1 � TOWN OF BARNSTABLE LOGA!--=JN /Q SCOAbn 1'1r SEWAGE # VILLAGE W. B A(✓1 S+4k ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) C� . (oX&J f�'i S (size) SOW GA'• NO. OF BEDROOMS 3 BUILDER OR OWNER B r N 54,' rC.t/1 G/ 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 leachin facility) Feet sto Furnished by �n 4� F'oi� Al q�- ICI ct i 131- 3a Aa- so a A3- Wy (33- 7 1 Ay- 46 TOWN OF BARNSTABLE I.O( =Al'ION /Cj ice,-,.-To SEWAGE # ' i VILLAGE. ,q/07 " �. / �,rr► %�, ASSESSOR'S MAP & LOTI/L INS'_"ALLER'S DIAME & PHONE NO.L�. ��>✓,��r -rS :Lk �.. SEPTIC TANK CAPACITY LEACHING FACILITY:(type) r (size) l p,f- 0 _ . NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER_ DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: 0 VARIANCE GRANTED:. Yes No 1 dy' /711 0 No..jly:.ld 7... Fss.....$....� THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ..----..T.o.wn.... ................O F.........Ba rns.tab l_.e------------...-----------------................. Appliratiou for UhipasFal Works Towitrurti aat rani# Application is hereby made for a Permit to Construct ( ) or Repair ]kX) an Individual Sewage Disposal System at: 10 Scorton Hill Road West Barnstable Location-Address or Lot No. ............. ra.I)eE} ...................................................... ..........-•...................................................................................... Owner Address W .J-•-p..1v1acamber...J.r---......................................... Installer Address Type of Building Size Lot----------------------------Sq. feet U Dwellings No. of Bedrooms............3.............................Expansion Attic ( ) Garbage Grinder ( ) '4 Other—Type T e of Building No. of persons............................ Showers Ga YP g -•------•------•------------ P ( ) — Cafeteria ( ) 04 Other fixtures ------------------------------•--•---••------ 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 No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I----------------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........................ P4 •-•--•-------------------------•-------------------•--•.....-•----------._..........._.._-----------......................................................... 0 Description of Soil........................................................................................................................................................................ U ........................................................Sand W UNature of Repairs. or Alterations—Answer when applicable------------- l.]C2xl...p i_t----------------------------------- -----------------------------------------------------------•------------...........----------._.....-----------••-••---•----•----•----•--•--•--•-•---------------•-------•----------------------------•- Agreement: The undersigned agrees to install the afor edescribed Individual Sewage Disposal System in accordance with f"1T P1:-� the provisions of 1: . of the State Sanitary Code—The ndersigned further agrees not to place the system in operation until a Certificate of Compliance has befn issue by e d of he h. Signe t!----------------• ......4,<2-7-/`-81...... Date ApplicationApproved By.......... ..........•.-•--- ....................................................... --•- ............. -�--- Date Application Disapproved for the following reasons-------------•-----------------------------------------------•-•-----------------------------•-------------.----- ..................................•-•-----...._....----------...-•--••---------------•-•---•------•--•---I-------•-----•-----------•-•---•----•--•-----•------•----------------------•-----------...----- Date Permit No.. W _ Issued-_ J THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ApplirFation for Bhivvii al Works C�naao r c uan`" rr t Application is hereby made for a Permit to Construct ( ) or Repair (. .) an Individual Sewage1-Di,posal System at: y� s� ............ ...LS5� ._.. ------------------------------------------------------------ Location_Address or Lot No. q r. _ ........-...?!ems-':^i-^ �C.W]l-------------------------------------------------------- ..........__...................................................................................... Owner Address (� ........ =1�4:1' ;;:=`x Jr- ----------------------•---•--------••-----•-----------•---------------------------------•--------- Installer Address Q Type of Building Size Lot............................Sq. feet DwellingX.—No. of Bedrooms............3______________________________Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) QOther fixtures ---------------•------------------------------------•--------.-.----------------------....._..._...------------------•----...._..--•--.........._._._. 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 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----------_............. (x, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water_-_____________________- -----------------------------------------------------------•------------------•----•---•..__......--.........................................................O Description of Soil_________________________ x U U - -- -•----------------------------------•••-•••--•-•-----------------------...----•-••---•------••-•---------------• .. . ... .?_.3.._:- `:a4.____________________________________ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with T�'Ix the provisions of 'f"Iy t l.,,. 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 byre bard of health. Signed_ k.11) - r..�f >r��.lnf.. �� ._--------•---•. -- -•� ' ----- ✓ `c %.Date O'`^p Application Approved By---•-•••-----•--•-----•-••-•-••t�-----------•-••------------•--............................... .............. ... .... ------.... Date Application Disapproved for the following reasons------------------------•---••--•----------------------------•-------------------•-----------------._....._------ .................•--------------------------•------------•-----------•--•--------•---...----------••-------•-•.._...._....------•----•••-•-•-•-•-•----------••---------•-•----••--• •-••-•---------•-•- Q / Date Permit No°---U._�.....f Issued--•--- -._ f__ ? ./VrF-F--•------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH rat~- Tntifiratr of Toutplitanrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired by....... = '" Installer has been installed in accordance with the provisions of TITiE; 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No----------------------------------------- dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE___,J� 2�.� ��------------------------------••---- Inspector--------•-•-•- ��_'•_-0.---•---------.._.......----•--------.............-- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ��-/q T. ?:.........................OF......._�'i .aEi�a_1a-1_5'.............................................. PTO.................. ... FEE... ...??7... . Disposal Workii Tonotrudion rruti# Permission is hereby granted------ A........................................................................................... to Construct ( ) or Repair-`VtZ ) an Individual Sewage Disposal System ' C3 -- 3^ at NO- -•------------- ------ h ,.. R0 • ti rSI .YZ1`. . ?rti1r=:j -....................................................................................................................................................------•--••----•----___._---•---••----------•-••-•--•-•-•---••-----•--••-----•---•-- Street as shown on the application for Disposal Works Construction Permit No. - --------••---------------•-•- ---_--- -----------•-------••-- - -- Board of Health DATE `� FORM 1255 HOBBS &WARREN, INC., PUBLISHERS -- r Fzs. 5, 41 No..-•-.....•--..._....... THE COMMONWEALTH OF MASSACHUSETTS ' / BOARD O �-1 EA o � ,v L �. /0 i SGQly 1 ...OF............ ... . ............................. ApplirFation for Bispvii al Workii Tonstrnrtiun ramit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: xo,& ....C...... ....... ---------------------------------- Location-Address or Lot No. Owner .Address F� ................................................... ........................................... .........................................Z j Installer Address Type of Building _, Size Lot. : .Sq. feet Dwelling�No. of Bedrooms................. .....................Expansion Attic ( ) rbage Grinder Other—Type of Building No. of persons............................ Showers — Cafeteria Otherfixtures -----------------------•-----...---•------...............----•---------------------------------------------....-----------------••....--•-----• ---- W Design Flow-- --------------3�� allonsper person per day. Total daily flow... ,' ....... Design WSeptic Tank. Liquid capac ..... ength................ Width---- ......... Diameter---------------- Depth... x Disposal Trench—No_ ____________________ Width ........ Total Length...... Total leaching area..4 !..sq. ft. Seepage Pit NO..._..I---------. Diameter.................... Dep -i below 'qlet............._._.... Total leaching area..................sq. ft. Z Other Distribution box ( Dosing to � Percolation Test Results Performed by....l__ Av__._ - ✓:................. Date...... aTest Pit No. 1...... minutes per inch Depth of Te Pit____________________ Depth to ground water........................ 1� Test Pit No. 2.................minutes per inch Depth of Test Pit.................... Depth to ground water........................ . x � .O Description of Soil..... ... ....... . �- --- / - - --------------------------- ------------ ------------------------------------------------------ ------------------------------------- ------------------------------------------- ------------ x -----------------------------------------------------------------------------------------------------------------------------------------------------------------------•-••--------------------•-------- V Nature of Repairs or Alterations—Answer when applicable............................................................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of L I",LE 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. Sie -4- -. - - - - ------------------- .............------------------- Date 7Application Approved By •.. 8 �_.. °. =- .........f_= eI /Application Disapproved for the following reasons:................ Date -------------•--••--•-------•----------•----------------------..:---....--=----------------_.... ..............•--------------•---•-•-----....---•--•--------•------------•------.......----•---------•------------------.....------------------....--------------------------------------------------•-- Permit No.... ...... Issued-•-•�--- - 7 Date Date l 9 No. .. Fs$....1r5�`--� THE COMMONWEALTH OF MASSACHUSETTS . BOARD O �-1 EA ................. ...OF......-.... ,{{ ......... .... ApplirFationfur Disposal Works Tonstrnr#iun rrrmit Application is hereby made fora Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: 44 00— X/. 46,f teVs> ,gip. �il�1'At.%sr .................._......... --•-•-----........................ .......................... ..............................................1' ..-• .. -.......__._......... ..- Location-Address or Lot No. .... Location ................ ...............................•--••-...... ....•--•--.--.•-•-..._.............._......._. ... - Owner Address Address Installer *f 4* Ll Type of Building Size Lot_ __ : ��. .?.! _Sq. feet Dwelling/VNo. of Bedrooms............. .....................Expansion Attic Gfrbage Grinder `4 Other—Type e of Building No. of persons............................ Showers / � YP g ---------------•--..._...... p ( ) — Cafeteria Otherfixtures -------••---------------•-----......--••--------------.....-------•-------•---•----------------------........... Desi Flow... "".�� __ _.. s per person per day. Total daily flow..... : ......gallons. W gn .. 45 7----�..g P P P Y Y 9�' Septic Tank Li uid ca acit i'' allons en h________________ Width... Diameter..._.__...__..__ P / q P YDept, x Disposal Trench—No..................... Width../a.._...... Total Length........_.... Total leaching area.' _ ..sq. ft. Seepage Pit No...._../........ Diameter.................... De i elow • et.................... Total leaching area......:..........sq. ft. Z Other Distribution box O Dosing ta. ✓` )' Percolation Test Results Performed by.._.f_ _L(e4.__hit .................. Date...... "..1.!z_` •. Test Pit No. L__ ?!"_.minutes per inch Depth 'of Te .................... Depth to ground water;......____._..._.:..._. 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ D Description of Soil ' :.". '. -.. � ".... �. 17• {. ,;� �5 ' "►� --------------------=--------------------------------------------------------.................................................................................. W - -----------------------------------------------------------------------------------------------------------------------------------------------------------------•---------------•-......•---••-••-••-- V Nature of Repairs or Alterations Answer when applicable...................................................... ............................................ a, ............................................_.............-....._......_.............._.._....._.................... Agreement The undersigned agrees to install the afore'described Individual Sewage Disposal System in accordance with the provisions of LI' .,, 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. Sign Date Application Approved BY '' _a.. jr/1. ... . ....A..............•-...__.... Date Application Disapproved for the following reasons-------------••• ••-•-•---•-••--•-•-•---••---••----•-•••••••-••--•-••-•-••••-••--•-......-••••••......-•-....._ ............................................•........---.......-•--------....-•--•--------••----------•--------------------------•----------------------^------------------.....------------------_.._ Permit No......................................................... Issued_......�.......... ............(....Date Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF H ALTH rOF................... ..: ! .... ..;...........................---• #ifirtt�.e n fa.�aait�li�anr.� - , �,,..%..- ...........];/;00;�k THIS IS TO CEI. IFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by:.... : :w: u�� ---------*------- ------------------------ ......... .. ..... ... .4 I tal at has been installed in accordance with the provisions of F 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No ,__ ..... rx_-z.._.__...... dated__ _.... . . ................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORYt DATE... ... .... Inspector---...._�L%% ! ................... ,. :1 THE COMMONWEALTH OF MASSACHUSETTS BOARD HEALTH ........... ........OF...... N .............. FEE � Disposal Vorkp Zonstrurtion jhrmit Permission reby granted �`�<. ::Y�` ----.................... - --•-••--------- to Construc o&"eyair . ) an Individual Se Dis,$osal Street - . as shown on the applicahon'for Disposal Works Construction Per t No i'� �r2 ted.. 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