HomeMy WebLinkAbout0007 TILLAGE LANE - Health �7 Tillagi "Lan
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CERTIFICATE OF ANALYSIS
Barnstable County Health Laboratory (M-MA009)
9sr����yst^i Report Prepared For: Report Dated: 4/28/2015
Sean Jones
SM Jones Title 5 Septic Inspection Order No.: G1586310
74 Beldon Ln.
Centerville, MA 02632
Laboratory ID#: 1586310-01 Description: Water-Drinking Water
Sample#: Sample Location: 7 Tillage Lane West Barnstable, MA Collected: 04/21/2015
Collected by:
Received: 04/21/2015
Routine
ITEM RESULT UNITS RL MCL METHOD# TESTED
Nitrate as Nitrogen 3.3 mg/L 0.10 10 EPA 300.0 4/21/2015
Copper 0.42 mg/L. 0.10 1.3 SM 3111 B 4/24/2015
Iron 0.15 mg/L 0.10 0.3 SM 3111E rr 4/24/2015
pH 6.5 PH AT 25C NA 6.5-8.5 SM 4500-H-13 4/21/2015
Sodium 110 mg/L 2.5 20 SM 3111E 4/24/2015
Total Coliform Present P/A 0 0 SM 9223 4/21/2015
Conductance 710 umohs/cm 2.0 EPA 120.1 4/21/2015
Recommended maximum contamination level exceeded due to Coliform Bacteria, Tested Negative for E.coli. Sodium
level is above the maxium contaminant level. Those on a low sodium diet may wish to consult a physician.
Attached please find the laboratory certified parameter list. Approved By: /
(Lab Director)
ND=None Detected RL Reporting Limit MCL=Maximum Contaminant Level
Superior Court House, PO. Box 427, Barnstable, MA 02630 Ph: 508-375-6605
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cZtwm under Ma.3s.General,laws QutptW40X-,.5eCt1'01V 7- Fite. No, 0r 04r_3
PLEASE NOTE: The structures as shown on this plot plan are approximate only. An actual survey is nccc-.,tary for a precise
determination of the building location and eneroachment_a• if any exist. either way across property lines. This plan mutt not he
used for recording purposes or for use in preparing dted descriptions and must not be Used for variance or building plan i
purposes. This plan must not he used to locate property lines. Verification of building locations. property line dimensions. fences
or lot configuration can only be accomplished by an accurate Instrument survey which may reflect different information than what
15 shown hereon. Please note that this is "NOT A BOUNDARY SURVEY' and is 'FOR MORTGAGE PURPOSES ONLY'.
COLONIAL LAND SURVEYING COMPANY, INC.
' 20 Hanover Street • Hanauer, Mao.02339 - Phone: 791-826-7186 . • Fax:781-326.4823
TOWN/OF BARNSTABLE
LOCATION ���/Gt 'C� L-i�1 SEWAGE i�A7Y--ee'f sy^
VILLAGE ASSESSOR'S MAP & LOT
INS E-R'S NAME&PHONE NO. ft�'C fc-O�JAVA 2!
SEPTIC TANK CAPACITY SS V
LEACHING FACILITY: (type) O' , 'r (size) C300
NO.OF BEDROOMS
BUILDER OR WNE� l � ` Z
PERMIT DATE: C�E 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
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ss
i C� L cam— TOWN OF BARNST LF clue-,
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LOCATION ti SEWAGE' s. >
VILLAGE ASSESSOR'S MAP,& 60-T,
s
INSTALLER'S NAME & PHONE NO, ra
SEPTIC TANK CAPACITY
A �
LEACHING FACILITY:(type) .� (size)
NO. OF BEDROOMS- PRIVATE WELL OR PU LIC WATER e6
BUILDER OR OWNER (( e t
DATE PERMIT IS UED: '
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No `"'�
} cr v
•� Y
L'
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ASSESSORS MAP NO: �3
PARCEL N0:
No................... Fx$............._............
THE COMMONWEALTH OF MASSACHUSETTS
laig-y BOAR® OF �-1 ALTH
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IU ...........................................OF.......... �............_...._.. .................................................
ApplirFation for UispwiFai Iforks Tomitrurtivit ramit
Application is hereby made or a mi �to�onstruct ( ) or Repair ( an Individual Sewage Disposal
System at: y✓� J 1 vS f
iid�� - ,
...............- d.F"F'... 1�.N�? c - .....-----= .......------- ..:- •--..._.._._...._...............-....-----_..
o ati re or Lot No
---------------A.A.aa.. .P. ..._..........fft.-ORK ••-------- ,-L-�; -6.. ...........
Owner A dress
••_. ... .....--- -
Installer Address
dType of Buildin Size Lot............................Sq. feet
V Dwelling . No. of Bedrooms.__......__ p g ( )
.� rL___________________________Ex Expansion Attic (r Garbage Grinder
PL4
Other.—T e of BuildingNo. of persons......-_-•----------------- Showers — Cafeteria
Otherfixtures -------AI&N-'r------------------------------------------------------------------------------------------------------------------------
W Design Flow.........................................�.q gallons per person er day. Total daily flow............................................gallons.
C� Septic Tank—Liquid ca.pacity..��lJ-gallons Length ..
Width................ Diameter---------------- Depth................
Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
3 Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by................. ........................................................ Date..........................................
aTest Pit No. 1________________minutes per inch Depth of Test Pit.................... Depth to ground water........................
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water----------..............
Pr' ------------------ ...............-..........................................................................................................................
0 Description of Soil....................................................................................................................................................------•••-----•-----
x
UNatur f1��}�'e irs or Iterations—Answer wh----applicable.------C�J� " -d------ v
_._.______ .__..._.. ________ ____ ____ ________ ___'........___.____..__._....______....__._._._.... ....___.. ..___.._.._._...__.___._..____......_......._..
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of i T'�t'1 r of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has be n issed Pyboard of health.
Signed ' r
�>
.Application Approved B 111LVY. -•••. ----``- -----------------------------•---•----•--------•------ at
e
Application Disapproved for the f ollowi g reasons-----------------------------------------------------------------------------------------------------------•••-
...---••----•-•--•--._......--•-•-•---•-•---••-••••-•---•...............•--•-=•----.....-----••-••---------••-••=•-•••••••-•----••----•---------•----•-•----•--------•-----------•------•---...-•-•--
Date
tt��r
PermitNo......... ------•-------- Issued.......................................................
Date
No................_.....� Fula....
Fula
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
........................ . ...-..........OF..........�j.....(..'.'� N—S
Apphration for Disposal Works Tonstrnrtion Vrrmff
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
•..............._..---------...............................--------------•••--••----•-•--•....... --•---...._..-•-------............-------•----••--••••--•-•--•••-•-•------•--•._.........---------
Location-Address or Lot No.
................................................................................................. ..........-•------------•---•-------•-.......------------........._...............................
Owner Address
W '
Installer Address
Type of Building Size Lot.,..........................Sq. feet
V Dwelling—No. of Bedrooms............................. .Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
aI Other fixtures .................................. ......
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
9 Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter__-_____-___..__ Depth................
Disposal Trench—INo.____-___--_---___- 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........................................
,4 Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water.........................
G%4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water-.__•______-____---__-__
a'
0 Description of Soil....................................................................................................................................................---......_...------
x
U
W -
U Natur -�o R 'airs or Iterations—Ans er wh applicable.----------------------------------
--.__.F ...................................` _:_..___.
____ ___________________________ �_____:_�_j............... ...............................................................................................................
Agreement:
The undersigned agrees to install the afor edescribed Individual Sewage Disposal System in accordance with
the provisions of'TT j 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.
Signed
- •-- ..' --•--•-------------•-
APPlication Approved BY ---- - . ••--•- ------------------------••--••----••-• ----- at f
--- -----
/ Da e i
Application Disapproved for the f ollowidgc reasons:-----------•--•--•---------••--------------------------------------------•----....------ -----•---------.....__
---•----....--•-----...---•------------------------------•--•-------------•------•-------------••----•-----.........._......---------------••----.....------------•---•---•-----------------•-•.._._.._.
Date
PermitNo....................:...................................• Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HE TH
!�
OF.................(......�.!...............'......................................
Tnr#ifiratr of Tontpliu to
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
b ........................ ------� ------------------------------------------------------------------- ._....._.. ...
t // I L
\J
has been installed in f1cordance with the provisions of T'V 5 of Th State Sanitary Co as scr ¢ m the
application for Disposal Works Construction Permit No._ _-_.__. _._:: �' dated_--.._-_�-.�_____..__r_
_> . --••-• - --- ---------- 1
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT YHE
SYSTEM WILL FUNCTION SATISFACTORY.
,� ......•--•- Inspector...---_
DATE..................... -•'•-•�---�-...�F . ----.....-•----- ...... ...... -----•--•---
THE COMMONWEALTH OF MASSACHUSETTS
BOARD-, OF
HEALTH /J
ts
OF.....................................................................................
Nofl ! FEE........................
Disposal orks Tono#r ion amit
Permission is hereby granted------------- .......L.�:t.!!.'.L✓ -- -•---•--.....----...........---•-•---•--.........---•----....
to Constr>�t ( ) or Re air � ) n I dividual Sewag D' po al S.. sx
at o. E �— - -- -). /S ....
as shown on the application for Disposal Works Construction Pe sT ttNo.:_ ySJ� ted._______....i!... ......... ........
Board of Health
DATE.......... ........--
FORM 1255 HOBBS & WARREN. INC., PUBLISHERS
r
y LogNumber: 7056 Bottle #
E7.3�_ Date: 7-29-87
�� sa BARNSTABLE COUNTY HEALTH AND ENVIRONMENTAL DEPARTMENT
5
SUPERIOR COURT HOUSE
O BARNSTABLE, MASSACHUSETTS 02630
J
o
�1Ag9 DRINKING WATER LABORATORY ANALYSIS PHONE: 362-23I1
Ext, 337
Client: G.M. Rourke Collector: William D.Mullin,Jr.
Mailing Address: Sandy Neck Rd. Affiliation:
W.Barnstable, MA 02668 Time & Date of 7-28-87
Collection: 11:00 a.m.
Telephone: 362-6472 Type of Supply: well
Sample Location: Sandy Neck Rd. Well Depth: 72 '
W.Barnstable, MA Date of Analysis: 7-28-87 lla.m:-
PARAMETER SAMPLE RESULT RECOMMENDED LIMI_T_S
Total Coliform Bacteria/100 ml 0 I 0
PH 5.6
t _
Conductivity (micromhos/cm) 122
500.0 i
Iron (ppm) •9 0.3
Nitrate-Nitrogen (ppm) 1.4 i 10.0
Sodium (ppm) 10
t 20.0
I . Water sample meets the recommended limits for drinking of all above tested parameter:
II . XX Based only on results of the parameters tested for this sample, the water is
suitable for drinking but may present the problems checked below:
A. 6dater sample has higher than average levels of Nitrate. Future monitoring is
recommended (2-3 times per year) to establish any upward trends.
B".— The low -pH 'of the water may shorten the 7usefu1 life of the house 's plumbi►�y.
C. XX Water may present aesthetic problems (taste, odor, staining) due to Iron
D. Water sample has high levels of sodium. Persons on low sodium diets should
consult their doctor.
III. Due to one or more of the reasons checked below, this water sample is unfit for
human consumption: A. High Bacteria B. High Nitrates
The Barnstable County Health and Environmental
REMARKS: Department shall not endorse any statements,
s ` interpretations or conclusions made -by anyone
else concerning these results without written consent.
/
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CC: Barnstable ��n
Board of ,Health ! �
C C:
lod , _
- f I �taborc tot y Director
for
Health Master Detail Page 1 of 1
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Logged In As: TOWN\health _ Health Master Detail Monday, February 23 2015
Application Center Parcel Lookup Selection Items
{ Parcel Septic Perc Well Fuel Tank
Parcel: 136-005 Location: 7 TILLAGE LANE, WEST BARNSTABLE Owner: GILLIGAN, MICHAEL B&ANNE R
Business name: Business phone:
I Rental property: r Deed restricted: ri Number of bedrooms : 0
Contaminant released: 17 Fuel storage tank permit: r
"Save Parcel Changes; . �. Return to Lookup
Parcel Info Parcel ID: 136-005 Developer lot:
Location:7 TILLAGE LANE Primary frontage: 138
Secondary road: Secondary frontage:
Village:WEST BARNSTABLE Fire district:W BARNSTABLE
Town sewer exists at this address:No Road index:1718
17
136005_1 '
Asbuilt Septic Scan: Interactive map: I r ,
136005_2
Town zone of contribution:AP (Aquifer Protection Overlay District)State zone of contribution:OUT
Owner Info Owner: GILLIGAN, MICHAEL B &ANNE R Co-Owner:C/O GILLIGAN, MICHAEL B
Street1:49 PHEASANT HILL DR Street2:
City:SCITUATE State:MA Zip: 02066 Country:
Deed date:4/14/2006 Deed reference:20916/221
Land Info Acres: 1.00 use: Single Fam MDL-01 Zoning:RF Neighborhood: 0110
Topography:Level Road:Unpaved
Utilities:Gas,Well,Septic Location:Water View
Construction Info Building No ear Buil Gross Area Living Area Bedrooms Bathrooms
1 1960 3234 1326 2 Bedroom 1 Full-1 Half
Buildings value:$105,500.00 Extra features: $36,600.00 Land value: $334,800.00
http://issgl2/intranet/healthMaster/HealthMasterDetail.aspx?ID=136005 2/23/2015
Commonwealth of Massachusetts
w `title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
7 Tillage Lane
Property Address
GILLIGAN, MICHAEL B &ANNE R
Owner Owner's Name
information is West Barnstable Ma 02668 10/1/2012
required for 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. Please see completeness checklist at the end of the form.
Important:When filling out forms A. General Information
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not Sean M. Jones
use the return Name of Inspector
key.
S.M.Jones TitleV Septic Inspection
Company Name
74 Beldan Ln.
Company Address
Centerville Ma 02632
City/Town State Zip Code
774-248-4850 smonestitle5@gmail.com SI4522
Telephone Number A o Number
o e4,fiIfsLicense �i�
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
10/1/2012
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.
t5ins-111110 Title 5 Official Insp i Form:Subsurface Sewage Disposal System•Page 1 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 7 Tillage Lane
Property Address
GILLIGAN, MICHAEL B &ANNE R
Owner Owner's Name
information is required for every West Barnstable Ma 02668 10/1/2012
page. Citylrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® 1 have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
The dwelling located at 7 Tillage Lane West Barnstable is served by a Title V septic system
consisting of a block cesspool, distribution box and a 1000 gallon pre-cast leach pit.
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain. '
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND(Explain below):
t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17
I
Commonwealth of Massachusetts
F Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
7 Tillage Lane
Property Address
GILLIGAN, MICHAEL B &ANNE R
Owner Owner's Name
information is required for every West Barnstable Ma 02668 10/1/2012
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
7 Tillage Lane
Property Address
GILLIGAN, MICHAEL B &ANNE R
Owner Owners Name
information is required for every West Barnstable Ma 02668 10/1/2012
page. CityrTown State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes"or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than '/day flow
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
7 Tillage Lane
Property Address
GILLIGAN, MICHAEL B &ANNE R
Owner Owner's Name
information is required for every West Barnstable Ma 02668 10/1/2012
page. City/Town State Zip Code ' Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in'a nitrogen sensitive area(interim Wellhead Protection
Area—IWPA) or a mapped Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,
or answered"yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
7 Tillage Lane
Property Address
GILLIGAN, MICHAEL B &ANNE R
Owner Owner's Name
information is required for every West Barnstable Ma 02668 10/1/2012
page. Cityrrown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no"as to each of the following:
Yes No
❑ ® Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
❑ ® Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS)on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms(actual): 2
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 gpd
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 7 Tillage Lane
Property Address
GILLIGAN, MICHAEL B &ANNE R
Owner Owner's Name
information is required for every West Barnstable Ma 02668 10/1/2012
page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 0
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
Seasonal use? ® Yes ❑ No
Water meter readings, if available(last 2 years usage(gpd)):
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: vacantDate
Commerciallindustrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
7 Tillage Lane
Property Address
GILLIGAN, MICHAEL B &ANNE R
Owner Owner's Name
information is required for every West Barnstable Ma 02668 10/1/2012
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
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) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
7 Tillage Lane
Property Address
GILLIGAN, MICHAEL B &ANNE R
Owner Owner's Name
information is required for every West Barnstable Ma 02668 10/1/2012
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
cesspool is original, distribution box and leach pit added later
Were sewage odors detected when arriving at the site? Yes No
9 9 ❑
Building Sewer(locate on site plan):
Depth below grade: 2
feet
Material of construction:
❑ cast iron ❑40 PVC ❑ other(explain):
Distance from private water supply well or suction line. 10+feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
Joints,ok, no leakage, vented through roof
Septic Tank(locate on site plan):
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:
Sludge depth:
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
a
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 7 Tillage Lane
Property Address
GILLIGAN, MICHAEL B &ANNE R
Owner Owner's Name
information is required for every West Barnstable Ma 02668 10/1/2012
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
How were dimensions determined?
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
7 Tillage Lane
Property Address
GILLIGAN, MICHAEL B &ANNE R
Owner Owner's Name
information is required for every West Barnstable Ma 02668 10/1/2012
page. CityrFown State Zip Code Date of Inspection
D. System Information (cont.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dim
ensions:
Capacity:
gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
"Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
7 Tillage Lane
Property Address
GILLIGAN, MICHAEL B&ANNE R
Owner Owner's Name
information is required for every West Barnstable Ma 02668 10/1/2012
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
0"
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
D-box was video inspected and found to be in good condition.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M , 7 Tillage Lane
Property Address
GILLIGAN, MICHAEL B &ANNE R
Owner Owner's Name
information is required for every West Barnstable Ma 02668 10/1/2012
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: 1x1000 gallons
❑ 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.):
Leach pit was found to be dry with a stain line approx 3'from the bottom indicating that the pit has
never been more than 50% full.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration 1
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool 6x6
Materials of construction
concrete block
Indication of groundwater inflow ❑ Yes ® No
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 7 Tillage Lane
Property Address
GILLIGAN, MICHAEL B &ANNE R
Owner Owner's Name
information is required for every West Barnstable Ma 02668 10/1/2012
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Cesspool was dry at time of inspection. Concrete blocks were in good condition. Outlet pipe has tee
intact.
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.):
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
4 Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
r� 7 Tillage Lane
Property Address
GILLIGAN, MICHAEL B &ANNE R
Owner Owners Name
information is required for every West Barnstable Ma 02668 10/1/2012
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Sketch O�Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
P
I
t
( -f Jos
Z
A'2 �, o
�"Z 3
3 sy
9_3 53 '
t5ins•11/10 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 15 of 17
l
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M , 7 Tillage Lane
Property Address,
GILLIGAN, MICHAEL B &ANNE R
Owner Owner's Name
information is West Barnstable Ma 02668 10/1/2012
required for every '
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: 20+
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:
Groundwater elevation was established by accessing Town of Barnstable groundwater contour maps.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
L
Commonwealth of Massachusetts
' rTitle 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 5 ' 7 Tillage Lane
Property Address
GILLIGAN, MICHAEL B &ANNE R
Owner Owner's Name
information is required for every West Barnstable Ma 02668 10/1/2012
page. Cityrrown State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
n r
DEPARTMENT OF ENVIRONMENTAL PROTECTION 'LL
f Z1`.
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 7 Tillage Lane
West Barnstable MA 02668
Owner's Name: Dorothy Eide
Owner's Address: P.O. Box 1094
East Sandwich MA S= 3a3 9
Date of Inspection: August 18,2005 Job 4 05-234
Name of Inspector: PATRICK M. O'CONNELL
Company Name: SEPTIC INSPECTION SERVICES CO.
Mailing Address: 189 CAMMETT ROAD
MARSTONS MILLS MA 02648
Telephone Number: 508-428-1779
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 ba� 7 Ink",
training and experience in the proper function and maintenance of on site sewage disposal systems ti1gS �i
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The syst • •'• �'�
_X_ Passes z �. RICK m'
Conditionally Passes — M.
Needs Further Evaluation by the Local Approving Authority `O-C N •c'`
Fails *`
Inspector's Signature. yv�
Date: August 18, 200 hfill it����
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving
authority.
Notes and Comments: Cesspool with overflow,observed no standing water in overflow pit.
****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 I
Page 2 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 7 Tillage Lane
West Barnstable MA 02668
Owner: Dorothy Eide
Date of Inspection: August 18,2005
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
_XX_ 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
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:
Tiff. C Tncnortinn I'nrm 41T Ci,)nnn 2
r
Page 3 of I 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 7 Tillage Lane
West Barnstable MA 02668
Owner: Dorothy Eide
Date of Inspection: August 18,2005
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.
I. System will passe 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 an
stem is functioning PP y)determines that the
system g 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:
Title G Incnuntinn v__Oil;i,)nnn 3
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 7 Tillage Lane
West Barnstable MA 02668
Owner: Dorothy Eide
Date of Inspection: August 18,2005
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
_X— Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
— _X_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
_X— Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
_X— Liquid depth in cesspool is less than 6"below invert or available volume is less than %day flow
_X_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
_X_ Any portion of the SAS, cesspool or privy is below high ground water elevation.
_X_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
_X_ Any portion of a cesspool or privy is within a Zone 1 of a public well.
_X_ Any portion of a cesspool or privy is within 50 feet of a private water supply well.
_X_ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. [This system passes if the well water analysis,
performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria
are triggered. A copy of the analysis must be attached to this forma
_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 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.
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)
es n y o
— _ 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 If 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.
Title G Incnartinn PArm (,/1 V)nnn 4
L
Page 5 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 7 Tillage Lane
West Barnstable MA 02668
Owner: Dorothy Eide
Date of Inspection: August 18,2005
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
Yes No
_X_ _ Pumping information was provided by the owner,occupant, or Board of Health
_X_ Were any of the system components pumped out in the previous two weeks?
_X_ _ Has the system received normal flows in the previous two week period ?
_X_ Have large volumes of water been introduced to the system recently or as part of this inspection
N/A Were as built plans of the system obtained and examined?(If they were not available note as N/A)
_X_ _ Was the facility or dwelling inspected for signs of sewage back up?
_X_ _ Was the site inspected for signs of break out
_X_ _ Were all system components,excluding the SAS, located on site?
_X_ — Were the septic tank manholes uncovered, opened,and the interior of the tank inspected for the
condition of the baffles or tees,material of construction, dimensions,depth of liquid, depth of sludge and depth of
scum ?
_X_ — Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS)on the site has been determined based on:
Yes no
_X_ Existing information. For example, a plan at the Board of Health.
X_ _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of
distance is unacceptable)[310 CMR 15.302(3)(b)]
T41A C IncnArtinn Fnrm 411 1;11)nnn 5
Page 6 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 7 Tillage Lane
West Barnstable MA 02668
Owner: Dorothy Eide
Date of Inspection: August 18,2005
RESIDENTIAL FLOW CONDITIONS
Number of bedrooms(design): 2 Number of bedrooms(actual): 2
DESIGN flow based on 310 CMR 15.203 (for example: 1 10 gpd x#of bedrooms): 220
Number of current residents: 5
Does residence have a garbage grinder(yes or no): No
Is laundry on a separate sewage system (yes or no): No [if yes separate inspection required]
Laundry system inspected(yes or no):
Seasonal use: (yes or no): No
Water meter readings, if available(last 2 years usage(gpd)): N/A Well Water
Sump pump(yes or no): No
Last date of occupancy: Currently Occupied
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):_
Industrial waste holding tank present(yes or no):_
Non-sanitary waste discharged to the Title 5 system(yes or no):_
Water meter readings, if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records: Last pumped: August 2004
Source of information: Owner
Was system pumped as part of the inspection(yes or no): No
If yes,volume pumped:_1000_gallons-- How was quantity pumped determined? Cesspool size
Reason for pumping: Septic inspection
TYPE OF SYSTEM
—Septic tank,distribution box, soil absorption system
_Single cesspool
_X_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:
unknown
Were sewage odors detected when arriving at the site(yes or no): No
Title C Teo tinn T7nrm 4/1 C/�Ml1 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: 7 Tillage Lane
West Barnstable MA 02668
Owner: Dorothy Eide
Date of Inspection: August 18,2005
BUILDING SEWER: XX (locate on site plan)
Depth below grade: 1 t
Materials of construction:_X_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: No (locate on site plan)
Depth below grade:
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:
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle:
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:
How were dimensions determined: STICK WITH HINGE FLAP.
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
GREASE TRAP: No (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.):
Titles C Incnant:nn Fnrm!./1 S;�l1/1!1 7
Page 8 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 7 Tillage Lane
West Barnstable MA 02668
Owner: Dorothy Eide
Date of Inspection: August 18,2005
TIGHT or HOLDING TANK: No (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: XX (if present must be opened) (locate on site plan)
Depth of liquid level above outlet invert: 0"
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage into or out of box,etc.):
No solids or high stains
PUMP CHAMBER: No (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.):
T41.f rl^— 411 VIM) 8
Page 9 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 7 Tillage Lane
West Barnstable MA 02668
Owner: Dorothy Eide
Date of Inspection: August 18,2005
SOIL ABSORPTION SYSTEM (SAS): XX (locate on site plan,excavation not required)
If SAS not located explain why:
Type
leaching pits,number:
leaching chambers,number:
leaching galleries,number:
leaching trenches, number, length:
leaching fields, number,dimensions:
_X_overflow cesspool, number: One 6x6 pit.
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.): Pit empty at time of inspection with no definite high stain lines
CESSPOOLS: Yes (cesspool must be pumped as part of inspection) (locate on site plan)
Number and configuration: One with overflow
Depth—top of liquid to inlet invert: 24"
Depth of solids layer: 4"
Depth of scum layer: trace
Dimensions of cesspool: 6x6
Materials of construction: Block
Indication of groundwater inflow(yes or no): No
Comments(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation,etc.):
Liquid level 14-16" below overflow invert Blocks are intact and structurally sound
PRIVY: No (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.):
Titles C hcv�Art�nn Rnrm 411 snnnn 9
Page 10 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAG
E DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 7 Tillage Lane
West Barnstable MA 02668
Owner: Dorothy Eide
Date of Inspection: August 18,2005
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.
Well 67' from
cesspool
Front 16
O
Garage #7
27
36
50
50
44 53
55
Titlo G fnc..nntin., Fnrm F.;1 ;�nnn 10
Page 1 1 of 1 I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 7 Tillage Lane
West Barnstable MA 02668
Owner: Dorothy Eide
Date of Inspection: August 18,2005
SITE EXAM
Slope None
Surface water None
Check cellar Dry
Shallow wells None
Estimated depth to ground water: More than 20 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:
_X_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)
_X_Accessed USGS database-explain: USGS topo map and town GIS
You must describe how you established the high ground water elevation:
Town groundwater contour map shows water below el.5 and topo map shows property above el.40.
T41. C Incnartinn f nrm 4/1 c110011 I 1
AUG-29-2005 10:13 BST CNTY LAB bUHJb221bb N.01/01
' <� ;fir;; � - - •--
P.
CERTIFICATE OFq. ANALYSIS
1 -nstable County 11e;11(h Laboratory
Itap.nl 1)a14-4: '7 251200.
Ctepol't Prt vaned For:
Orcler No.: G0531S42
Dorothy, Eide
P U Box 109:1
E S:mdlvich. MA 02i17
ID H_ 053 1 842-0 1 rh•sel•iplinn \\':Ilcr I)riuldll�\V;ucl•
$:un plr q; )IRJ2 ,am m.Luraiow 71'd];I"1.11.\\'.
►J:11'nilaldr.,1\'lA (:tillc.cicll: �/.I/211(I�
collrclell hy: J.kill Iedg-i• \I:Ip Ise Parcel oil:
Rcrii.rll; 7121/211r1i
'Rnutine
1TFM RESULT UNITS R(; MCI. Ix1crhnd3 Tcsrrd
LAB: 1110rpanivx
Nitt•ate as Nitrogen 3.4 u,g/I.. 0.10 Io EPA300.0 7;21/1005
Copper 0.53 rnb/L 0.10 1,) St,'I3111H 71' roo5
lrun 1.0 Illgn. n 1p u i stil.il tIG 7r22nuus
i
Sodium 33 I»,yl. I c, 2u spa)111D 7 22)�nns
LAR: Microhioln;p
Total Coliform Absent P/.> u u 3u9 7/71/1005
L.•JIl: Physical Che,ni3frp
Conductance 3-;U miloll'Am 1.0 F:I',11201 7/21!2005
1)t't 6.3 pN•unilc 0 I:Nn 150.1 7/2 1000 5
Sodium level is above Iht+Inaximun,coarnnlirl:ult level. Thom;un n low rullium diet m:iy wish to I.unsult a physician. May present
:u:srhetic problcaus(tnstc,odor,stninim;)duo to Inin,
\ .
(I/alt fC�lOfi
'n•I L'�_n'IBSiInUlll GPlll:h qil Gllll 1.2'.'r
5ul,crinr C1111 F'IcJtlsc. PO. lin\• .127. Barnstaple, MA 026311 })II: �!►£i-_7�-G(;(li
TOTAL P.01
AUG-24-2005 12:12 BST CNTY LAB 5083622186 H.01ib4
Page; 1
CERTIFICATE OF ANALYSIS
Barnstable County Health Laboratory
Report Doled: 9/24/2005
Report Prepared For:
Order No.: G0532580
Dorothy Eide
P 0 Box 1094
E Sandwick MA 02537
Laboratory ED#: 0532580-01 Descrlptton: Water-Drbddng Water
sample il: 32580 Satnplhtp Location: 7 71,01age Lo.W.Rarnstahle,MA Collected: R/17R005
Colkued by: J.KjWrdCc Mnp 136 Parcel 005 Received.. 9117/2005
EPA 524.2- Volatile Organics by GOMS
ITEM RESULT UNITS RL MCL Method Teytod
MD.- GUMS
1,1,1,2-Tetrachlorcethane BRL ug/L 0.5 FPA524.2 R/17n0os
1,1,1-Trichloroethane BRL ug/L 0.5 200 LPA524.2 a/17noos
1,1,2,2-Tetrachloroethane 13RL ur/L 0.5 F-PA 524.2 8/17/2005
1,1,2-Trichloroethane BRL ug/L 0.5 5.0 EPA 524.2 8/17/2005
1,1-Dichloroethane BRL tig/L 0.5 EPA524.2 9/17/2005
1,1-Dichloroethane BRL ug/1. 0.5 7,0 EPA 524.2 R/17/2005
1,1-Dichloropropene BRL ur/L 0.5 EPA 524.2 9/17n0o5
1,2,3-Trichlorobenzene BRL ug/L 0.5 EPA 524.2 R/17/2005
1,2,3-Trichloropropane BRL ur/1. 0.5 EPA 524.2 9/17/2005
1,2,4-Trichlorobenzene BRL ug/L 0.5 70 EPA 524.7 8/17/2005
1,2,4-Trimethylbenzene BRL ug/L. 0.5 EPA 524.2 8/17/2005
1,2-Dibromo-3-chloropropan BRL ug/L 0.5 EPA 524.2 9/17/2005
1,2-Dibromoethane(EDB) BRL ur/L 0.5 EPA 524.2 8/17/2003
1,2-Dichlorobenzene BRL v/L 0.5 600 EPA 524.2 9/17/2005
1,2-Dichloroethane BRL ur/L 0.5 5.0 h P A 524.2 9/17/2005
1,2-Dichloropropane BRL ug/L 0.5 EPA 524.2 8/17/2005
1,3,5-Trimethylbenzene BRL US/I. 0.5 EPA 524.2 8/172005
1,3-Dichlorobenzene BRL J1e/L. 0.5 EPA 524.2 9/1712005
1,3-Dichloropropane DRL uP/L 0.5 EPA 524.2 8/17/2005
1,4-Dichlorobenzene BRL ug/L. 0.5 5.0 EPA 524.2 9n7n005
2,2-Dichloropropane BRL ug/L 0.5 EPA 524.2 8/17/2005
2-Chlorotoluene BRL u&/L- 0,5 KPA 524.2 R/1712005
4-Chlorotoluene BRL up1L 0.5 EPA 524.2 8/17/2005
RL= ReportingLimn
MCL=Maximum Comamijmm Lavel
Superior Court Houve, P0.Box 427, Barnstable, MA 02630 Ph: 508-375-6605
AUG-24-2005 12: 12 BST CNTY LAB 5bti.5b221ab r.etley
y J;
Q CERTIFICATE OF ANALYSIS Page: j
Barnstable County Health Laboratory
Report Datad.: R/24/2005
Report Prepared For:
Order No.: G0532580
Dorothy Eide
P O Box 1094
E Sandwich, MA 02537
Benzene BRL us/L 0.5 5.0 EPA 524.2 8/17/2005
Bromobenzene BRL ug/L 0.5 FPA 524.2 8/17/2005
Bromochloromethane BRL ug/L 0.5 EPA.524.2 9/17/7005
Bromodichloromethane BRL ug/L 0.5 EPA 524.2 R117/2005
Bromoform BRL Uwt 0.5 EPA 324.2 9/17/2005
Bromomethane BRL ue/L. 0.5 EPA 524.2 8/17/2005
Carbon tetrachloride BRL ur/L 0.5 5.0 EPA 524.2 9/17/2005
Chlorobenzene BRL ag/L U.5 100 EPA 524.2 8/.17/2005
Chloroethane BRL ugn.. 0.5 EPA 574.2 8/17/2005
Chloroform BRL ug/L 0.5 EPA 524.2 R/.17/2005
Chloromethane BRL us/L 0.5 EPA 524.2 8/17/2005
CIS-1,2-Dichloroetbene BRL ug/L. 0.5 70 EPA 524.2 8/17/2005
cis-1,3-Dichloropropene DRL ur/L 0.5 EPA 524.2 8/1712005
Dibromochloromethane BRL ur/L 0.5 EPA 524.2 8/17/2005
Dibromomethane BRL ug/L 0.5 EPA 524.2 9/17/2005
Dichlorodilluoromethane BRL ug/L 0.5 EPA 524.2 9/17na0s
Ethylbenzene BRL ug/L 0.5 700 EPA 524.2 R/17/1005
Hezachlorobutadiene BRL ur/L 0.5 EPA 524.2 8/17/2005
Isopropylbenzene BRL ug/L 0.5 EPA 524.2 8/17/2005
Methyl-tert-butyl ether BRL us/1. 0.5 EPA 524.7 9/17/7005
Methylene chloride BRL ur/L 0.5 5.0 EPA 524.2 8/17/2005
u-Butylbenzene BRL ug/L 0.5 EPA 524.2 8/17/2005
n-Propylbenzene BRL ug/L 0.5 EPA 524.2 9/17/2005
Naphthalene BRL ug/L 0.5 EPA 524.2 8/17/2003
p-Isopropyltoluene BRL ug/L 0.5 EPA 524.2 8/17/2005
sec-Butylbenzene BRL ug/L 0.5 EPA 524.2 9/17/7005
Styrene BRL
u 0.5 IOU EPA 524.2 9/17/2005
tert-Butylbenzene BRL ug/L 0.5 EPA 524.2 8/17/2005
Tetrachloroethene BRL ug/L 0.5 5.0 EPA 524.2 8/17/2005
RL- lt"riingUmit
MCL=Maximum Cartaminwo Level
Superior Court House, PO. Box 427, Barnstable, MA 02630 Ph: 508-375-6605
f
AUG-24-2005 12:12 BST CNTY LAB 50B3b221Eb N.W/04
;Q CERTIFICATE OF ANALYSIS Page: 3
Barnstable County Health Laboratory
Report Doted. 9/24/2005
Report Prggared For
Order No.: G0532580
Dorothy Eide
P 0 Box 1094
E Sandwich MA 02537
Toluene BRL ug/t. 0.5 1000 EPA 524.2 9/17/2005
Total xylenes BRL ug/L 0.5 10000 EPA 524.2 9117/2005
trans-1,2-Dichloroethene BRL ur)L 0.5 1.00 EPA 524.2 8/11/2005
trans-1,3-Dichloropropene BRL ug/L 0.5 EPA 524.2 M/17n005
Trichloroethene BRL ug/L 0.5 5.0 EPA 524.2 X11712005
Trichlorofluoromethane BRL ugr1, 0.5 EPA 524.2 R/17/2005
Vinyl chloride BRL ug/L 0.5 2.0 EPA 524.2 1u17/2005
Water sample meets the recommended limits for drinking water of all the above tested parameters.
Approved
(LBb _ 6w)-
RL= RepoRing Limit
MCL-MsximumCorda nUwud Levr1
Superior Court House, PO. Box 427, Barnstable, MA 02630 Ph: 508-375-6605
Page: 1
CERTIFICATE OF ANALYSIS
Barnstable County Health Laboratory
Report Dated: 8/24/2005
Report Prepared For:
Order No.: G0532580
Dorothy Eide
P O Box 1094
--
E Sandwich, MA 02537
Laboratory ID#: 0532580-01 Description: Water-Drbddng Water
Sample#: 32580 Sampling Location: 7 Tillage Ln.W.Barnstable,MA Collected: 8/17/2005
Collected b J.Kittredge ge Map 136 Parce1005 Received: 8/17/2005
EPA 524.2 - Volatile Organics by GCMS
ITEM RESULT UNITS RL MCL Method# Tested
LAB: GC/MS
1,1,1,2-Tetrachloroethane BRL ug/L 0.5 EPA 524.2 8/17/2005
1,1,1-Trichloroethane BRL ug/L 0.5 200 EPA 524.2 8/17/2005
1,1,2,2-Tetrachloroethane BRL ug/L 0.5 EPA 524.2 8/17/2005
1,1,2-Trichloroethane BRL ug/L 0.5 5.0 EPA 524.2 8/17/2005
1,1-Dichloroethane BRL ug/L 0.5 EPA 524.2 8/17/2005
1,1-Dichloroethene BRL ug/L 0.5 7.0 EPA 524.2 8/17/2005
1,1-Dichloropropene BRL ug/L 0.5 EPA 524.2 8/17/2005
1,2,3-Trichlorobenzene BRL ug/L 0.5 EPA 524.2 8/17/2005
1,2,3-Tri chi oropropane BRL ug/L 0.5 EPA 524.2 8/17/2005
1,2,4-Tri chi orobenzene BRL ug/L 0.5 70 EPA 524.2 8/17/2005
1,2,4-Trimethylbenzene BRL ug/L 0.5 EPA 524.2 8/17/2005
1,2-Dibromo-3-chloropropan BRL ug/L 0.5 EPA 524.2 8/17/2005
1,2-Dibromoethane (EDB) BRL ug/L 0.5 EPA 524.2 8/17/2005
1,2-Dichlorobenzene BRL ug/L 0.5 600 EPA 524.2 8/17/2005
1,2-Dichloroethane BRL ug/L 0.5 5.0 EPA 524.2 8/17/2005
1,2-Dichloropropane BRL ug/L 0.5 EPA 524.2 8/17/2005
1,315-Trimethylbenzene BRL ug/L 0.5 EPA 524.2 8/17/2005
1,3-Dichlorobenzene BRL ug/L 0.5 EPA 524.2 8/17/2005
1,3-Dichloropropane BRL ug/L 0.5 EPA 524.2 8/17/2005
1,4-Dichlorobenzene BRL ug/L 0.5 5.0 EPA 524.2 8/I7/2005
2,2-Dichloropropane BRL ug/L 0.5 EPA 524.2 8/17/2005
2-Chlorotoluene BRL ug/L 0.5 EPA 524.2 8/17/2005
4-Chlorotoluene BRL ug/L 0.5 EPA 524.2 8/17/2005
RL = Reporting Limit
MCL=Maximum Contaminant Level
Superior Court House, PO. Box 427, Barnstable, MA 02630 Ph: 508-375-6605
Page: z
CERTIFICATE OF ANALYSIS
r:
Barnstable County Health Laboratory
Report Dated: 8/24/2005
Report Prepared For:
Order No.: G0532580
Dorothy Eide
P O Box 1094
E Sandwich, MA 02537
Benzene BRL ug/L 0.5 5.0 EPA 524.2 8/17/2005
Bromobenzene BRL ug/L 0.5 EPA 524.2 8/17/2005
Bromochloromethane BRL ug/L 0.5 EPA 524.2 8/17/2005
Bromodichloromethane BRL ug/L 0.5 EPA 524.2 8/17/2005
Bromoform BRL ug/L 0.5 EPA 524.2 9/17/2005
Bromomethane BRL ug/L 0.5 EPA 524.2 8/17/2005
Carbon tetrachloride BRL ug/L 0.5 5.0 EPA 524.2 8/17/2005
Chlorobenzene BRL ug/L 0.5 100 EPA 524.2 8/17/2005
Chloroethane BRL ug/L 0.5 EPA 524.2 8/17/2005
Chloroform BRL ug/L 0•5 EPA 524.2 8/17/2005
Chloromethane BRL ug/L 0.5 EPA 524.2 8/17/2005
cis-1,2-Dichloroethene BRL ug/L 0.5 70 EPA 524.2 8/17/2005
cis-1,3-Dichloropropene BRL ug/L 0.5 EPA 524.2 8/17/2005
Dibromochloromethane BRL ug/L 0.5 EPA 524.2 8/17/2005
Dibromomethane BRL ug/L 0.5 EPA 524.2 8/17/2005
Dichlorodifluoromethane BRL ug/L 0.5 EPA 524.2 8/17/2005
Ethylbenzene BRL ug/L 0.5 700 EPA 524.2 8/17/2005
Hexachlorobutadiene BRL ug/L 0.5 EPA 524.2 8/17/2005
Isopropylbenzene BRL ug/L 0.5 EPA 524.2 8/17/2005
Methyl-tert-butyl ether BRL ug/L 0•5 EPA 524.2 8/17/2005
Methylene chloride BRL ug/L 0.5 5.0 EPA 524.2 8/17/2005
n-Butylbenzene BRL ug/L 0.5 EPA 524.2 8/17/2005
n-Propylbenzene BRL ug/L 0.5 EPA 524.2 8/17/2005
Naphthalene BRL ug/L 0.5 EPA 524.2 8/17/2005
p-Isopropyltoluene BRL ug/L 0.5 EPA 524.2 8/17/2005
sec-Butylbenzene BRL ug/L 0.5 EPA 524.2 8/17/2005
Styrene BRL ug/L 0.5 100 EPA 524.2 8/17/2005
tert-Butylbenzene BRL ug/L 0.5 EPA 524.2 8/17/2005
Tetrachloroethene BRL ug/L 0.5 5.0 EPA 524.2 8/17/2005
RL = Reporting Limit
MCL=Maximum Contaminant Level
Superior Court Rouse, PO. Box 427, Barnstable, MA 02630 Ph: 508-375-6605
W' MM CERTIFICATE OF ANALYSIS SiS Page: 3
�,w,
Y
��ti:..,, Barnstable County Health Laboratory
r.`b ;.:
Report Dated: 8/24/2005
Report Prepared For:
Order No.: G0532580
Dorothy Eide
P O Box 1094
E Sandwich, MA 02537
Toluene BRL ug/L 0.5 1000 EPA 524.2 8/17/2005
Total xylenes BRL ug/L 0.5 10000 EPA 524.2 8/17/2005
trans-1,2-Dichloroethene BRL ug/L 0.5 100 EPA 524.2 8/17/2005
trans-1,3-Dichloropropene BRL ug/L 0.5 EPA 524.2 8/17/2005
Trichloroethene BRL ug/L 0.5 5.0 EPA 524.2 8/17/2005
Trichlorofluoromethane BRL ug/L 0.5 EPA 524.2 8/17/2005
Vinyl chloride BRL ug/L 0.5 2.0 EPA 524.2 8/17/2005
Water sample meets the,recommended-limits=f6r Atinking�water,of all the above tested-parameters. p
Approved By:
(Lab ' ector)
$1-24 �-
1
RL = Reporting Limit
MCL=Maximum Contaminant Level
Superior Court House, PO. Box 427, Barnstable, MA 02630 Ph: 508-375-6605
tier is T
�y CERTIFICATE E OF ANALYSIS AL g SIS Page: 1
Barnstable County Health Laboratory
Report. Dated: 7/25/2005
Report Prepared For:
Order No.: G0531842
Dorothy Eide
P O Box 1094
E Sandwich, MA 02537
Laboratory ID #: 0531842-01 Description: Water-Drinking Water
Sample 4: 31842 Sampling Location: 7 Tillage.Ln.NV.-13a stable,MA
Collected: 7/21/2005
Collected by: J.Kittredge Map l36 Parcel O115 Received: 7/21/2005
Routine
ITEM RESULT UNITS R.L MCL Method# Tested
LAB: Inorganics
Nitrate as Nitrogen 3.4 mg/L 0.10 10 EPA300.0 7/21/2005
LAB: Metals
Copper 0.53 mg/L 0.10 1.3 SM 3111E 7/22/2005
Iron 1.0 mg/L 0.10 0.3 SM 3111 B 7/22/2005
Sodium 38 mg/L 1.0 20 SM 311113 7/22/2005
LAB: Microbiology
Total Coliform Absent P/A 0 0 309 7/21/2005
LAB: Physical Chemistry
Conductance 350 umohs/cm 1.0 EPA 120.1 7/21/2005
pH 6.3 pH-units 0 EPA 150.1 7/21/2005
Sodium level is above the maximum contaminant level. Those on a low sodium diet may wish to consult a physician.May present
aesthetic problems(taste,odor,staining)due to Iron.
Approved By ref, c l
(Lab rector)
co
CD 1
RL = Reporting Limit
MCL=Maximum Contaminant Level
Superior Court House, PO. Box 427, Barnstable, MA 02630 Ph: 508-375-6605
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