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HomeMy WebLinkAbout0142 COACHMAN LANE - Health 142 COACHMAN' e- Marstons Mills j A = 151 — 029' _ C ff f Ile ' 5 0/, ! Commonwealth of Massachusetts Title v Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 142 Coachman Ln Property Address LEFKOVICH, MERYL&JOLY, MICHAEL G . Owner Owner's Name information is bl tae ns required for every W r MA 02668 6/16/2015 page. iTown 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 only the to r,. 0 �t//� use on{ the tab 1. Inspector: S G 1/ key to move your . cursor-do not Trevor Kellett use the return key. Name of Inspector TK Septic Inspections �y Company Name 38 Vacation Lane Company Address West Yarmouth MA 02673 City/Town State Zip Code 508-579-5502 S113744 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority '7/7/15 Inspectors 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•3/13 Title 6 OT6dai inspection Forth:Subsurface Sewage Disposal System•Page 1 of 17 1 r r r Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 142 Coachman Ln- Property Address LEFKOVICH, MERYL&JOLY, MICHAEL G Owner owner's Name information is required for every West Barnstable MA 02668 6/16/20151 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection, Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts ff Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments a w. 142 Coachman Ln Property Address LEFKOVICH, MERYL&JOLY, MICHAEL G. Owner Owner's Name information is required for every West Barnstable MA 02668 6/16/2015 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes:(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will passinspection 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•3113 Tille 6 Offical Inspection Form:Subsurface Sewage.Disposal System•Page 3 of 17 Y Commonwealths of Massachusetts Title 5 Official Inspection Form =, Subsurface Sewage Disposal System Form-Not for Voluntary Assessments W 142 Coachman Ln Property Address LEFKOVICH, MERYL&JOLY, MICHAEL G Owner Owner's Name information is required for every West Barnstable MA 02668 6/16/2015 page. City/Town 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: 1 **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 1/day flow t5ins•3113 Title 6 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 '�.. 142 Coachman Ln Property Address LEFKOVICH, MERYL&JOLY, MICHAEL G Owner Owner's Name information is required for every West Barnstable MA 02668 6/16/2015 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No El ® Required pumping more than 4 times in the last year NOTdue 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form,Not for Voluntary Assessments 142 Coachman Ln Property Address LEFKOVICH, MERYL&JOLY, MICHAEL G Owner Owner's Name information is required for every West Barnstable MA 02668 6/16/2015 page. City/Town 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 ❑ 0 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?. M ❑ 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): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 t5ins•3113 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 6 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 142 Coachman Ln Property Address LEFKOVICH, MERYL&JOLY, MICHAEL G Owner Owner's Name information is required for every West Barnstable MA 02668 6/16/2015 page. City/Town State Zip Code Date of Inspection D. System Information Description: This is a standard title v with a tank d box and 4 500g chambers Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundryon a separate sewage system? Include laundry sy stem stem inspection P 9 Y ( Y Y p information in this report.) ❑ 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: current Date Commercial/Industrial Flow Conditions: J Type of Establishment: Design flow(based on 310 CMR 15.203)i 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•3113 - Tifte 5 016dal Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form ,w Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 142 Coachman Ln Property Address LEFKOVIGH, MERYL&JOLY, MICHAEL G Owner Owner's Name information is West Barnstable MA 02668 6/16/2015 required for every page. City/Town 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•3l13 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 142 Coachman Ln Property Address LEFKOVICH, MERYL&JOLY, MICHAEL G Owner Owner's Name information is required for every West Barnstable MA 02668 6/16/2015 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 2-19-02 per boh Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1.8 feet Material of construction: ❑cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 12 p 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: 1000g Sludge depth: 4 t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Fora' Subsurface Sewage Disposal System Form-.Not for Voluntary Assessments r 142 Coachman Ln Property Address LEFKOVICH, MERYL&JOLY, MICHAEL G Owner Owner's Name information is West Barnstable MA 02668 6/16/2015 required for every page. City/Town 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 25 V, Scum thickness 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 17 How were dimensions determined? measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): tank is structurally sound and water tight with liquid at the outlet invert, both tees are fine,tank does not need to be pumped 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•3113 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 142 Coachman Ln Property Address LEFKOVICH, MERYL&JOLY, MICHAEL G Owner Owner's Name information is required for every West Barnstable MA 02668 6/16/2015 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow. gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3113 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 w 142 Coachman Ln Property Address LEFKOVICH, MERYL&JOLY, MICHAEL G Owner Owner's Name information is required for every West Barnstable MA 02668 6/16/2015 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) i 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.): d box is level and water tight with no carryover, 1 inlet and 2 outlets , d box is down 2.3'with a 1' riser Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): *If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System(SAS)(locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3113 Title 6 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 I Commonwealth of Massachusetts F Title 5 Official Inspection Form ' Subsurface Sewage Disposal System Form Not for Voluntary Assessments 142 Coachman Ln Property Address LEFKOVICH, MERYL&JOLY, MICHAEL G Owner Owner's Name information is required for every West Barnstable MA 02668 6/16/2015 page. City/Town State Zip Code Date of Inspection D. System Information (Cont.) Type: ❑ leaching pits number: ® leaching chambers number: 4 ❑ 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.): , The leaching of this property consists of 4 500g leach chambers there is no sign of failure in the stones or d box Cesspools(cesspool must be pumped as part of inspection)(locate on site plan).- Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 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 142 Coachman Ln Property Address LEFKOVICH, MERYL&JOLY, MICHAEL G Owner Owner's Name information is required for every West Barnstable MA 02668, 6/16/2015 page. City/Town State Zip Code Date of Inspection D. System information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.).- Privy(locate on site plan).- Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs'of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 Title 5 Offidal Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 'w. 142 Coachman Ln Property Address LEFKOVICH, MERYL&JOLY, MICHAEL G Owner Owner's Name information is required for every West Barnstable MA 02668 6/16/2015 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately front of house B A 1 A1)21 A2)33 2 B1)42.5 B2)47.5 t5ins•3/13 Tile 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 official Inspection Fora Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 142 Coachman Ln, Property Address LEFKOVICH, MERYL&JOLY, MICHAEL G Owner Owner's Name information is required for every West Barnstable MA 02668 6/16/2015 page. City/Town -'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: 150feet 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: pate ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with loca? 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 GW at 150 ft Before filing this Inspection Report,please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System+Page 16 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ,.0 .✓ 142 Coachman Ln Property Address LEFKOVICH, MERYL&JOLY, MICHAEL G Owner Owner's Name information is required for every West Barnstable MA 02668 6/16/2015 page. City/Town 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•3l13 Me 5 Offidal Inspedlon Form:SlbsuAace Sewage Disposal System•Page 17 of 17 CERTIFICATE OF ANALYSIS Page. of 1 Barnstable County Health Laboratory (M-MA009) 9s'�cxask' Report Prepared For: Report Dated: 10/30/2015 Tracey Oringer Order NO.. G1590923 , P O Box 2000 R.a Brewster, MA 02631 Laboratory ID#: 1590923-01 Description: Water-Drinking Water 'Y Sample#: Sample Location: 142 Coachman Lane, Collected: 10/28/2015 t:jjl Collected by: Customer M M Received: 10/28/2015 Routine ITEM RESULT UNITS RL MCL METHOD# ANALYST TESTED NOTE Nitrate as Nitrogen 0.51 mg/L 0.10 10 EPA 300.0 LAP 10/30/2015 Copper ND mg/L 0.10 1.3 SM 3111 B LAP 10/30/2015 Iron ND mg/L 0.10 0.3 SM 3111E LAP 10/30/2015 pH 6.0 PH AT 25C NA 6.5-8.5 SM 4500-H-13 DCB 10/28/2015 Sodium ND mg/L . 2.5 20 SM 3111E LAP 10/30/2015 Total Coliform Absent P/A 0 0 SM 9223 RG 10/28/2015 Conductance 16 umohs/cm 2.0 EPA 120.1 DCB 10/28/2015 Water sample meets the recommended limits for drinking water of all the above tested parameters. Attached please find the laboratory certified parameter list. Approved By: (Lab Director) /2- ND=None Detected RL = Reporting Limit MCL=Maximum Contaminant Level 3195 Main Street, PO. Box 427, Barnstable, MA 02630 Ph: 508-375-6605 Commonwealth of Massachusetts Title 5 Official Inspection Farm Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 142 COACHMAN LANE Property Address BETH WARNER 181 B HUMMOCK POND ROAD NANTUCKET MA 02554 Owner Ownqfs Name information is /�_I I S required for every -. a �S j MA 02668 6/19/13 page. Cityrrdwn- 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 Gary W Wing use the return Name of Inspector key. Gary W Wing Company Inc �y Company Name P.O. Box 984 Company Address Pocasset Ma 02559 City/Town State Zip Code 508-563-5288 S12521 Telephone Number License Number B. Certification o I certify that I have personally inspected the sewage disposal system at this address and that th information reported below is true, accurate and complete as of the time of the R spection. he i ection was performed based on my training and experience in the proper function and aintena tMe of f site sewage disposal systems. I am a DEP approved system inspector pursuant�to Sectio f 16.340 of Title 5(310 CMR 15.000).The system: i,? M ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority I p vs Sig a re Dat 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-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 or 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 142 COACHMAN LANE Property Address BETH WARNER 181 B HUMMOCK POND ROAD NANTUCKET MA 02554 Owner Owner's Name information is required for every W BARNSTABLE MA 02668 6/19/13 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 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. 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 over20 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): N/A t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 't 142 COACHMAN LANE Property Address BETH WARNER 181 B HUMMOCK POND ROAD NANTUCKET MA 02554 Owner Owner's Name information is required for every W BARNSTABLE MA 02668 6/19/13 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): N/A 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•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments .•' 142 COACHMAN LANE Property Address BETH WARNER 181 B HUMMOCK POND ROAD NANTUCKET MA 02554 Owner Owner's Name information is required for every W BARNSTABLE MA 02668 6/19/13 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: N/A **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: N/A 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 El ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow t5ins•09= Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 f Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments Y 142 COACHMAN LANE Property Address BETH WARNER 181 B HUMMOCK POND ROAD NANTUCKET MA 02554 Owner Owner's Name information is required for every W BARNSTABLE MA 02668 6/19/13 page. C4rrown 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 16,000 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-0908 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts UTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 142 COACHMAN LANE Property Address BETH WARNER 181 B HUMMOCK POND ROAD NANTUCKET MA 02554 Owner Owner's Name information is required for every W BARNSTABLE MA 02668 6/19/13 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): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form _a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 142 COACHMAN LANE Property Address BETH WARNER 181 B HUMMOCK POND ROAD NANTUCKET MA 02554 Owner Owner's Name information is required for every W BARNSTABLE MA 02668 6/19/13 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes 0 No Laundry system inspected? ® Yes ❑ No Seasonaluse? ® Yes ❑ No Water meter readings, if available last 2 ears usage d well 9 ( Y 9 (gP ))� Detail: see attached variancel Sump pump? ® Yes ® No Last date of occupancy: unknow Date Commerciallindustrial Flow Conditions: Type of Establishment: N/A 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts upTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 142 COACHMAN LANE Property Address BETH WARNER 181 B HUMMOCK POND ROAD NANTUCKET MA 02554 Owner Owner's Name information is W BARNSTABLE MA 02668 6/19/13 required for every page. City/Town 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: n/a 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•09= Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System form-Not for Voluntary Assessments •�'� 142 COACHMAN LANE Property Address BETH WARNER 181 B HUMMOCK POND ROAD NANTUCKET MA 02554 Owner Owner's Name information is required for every W BARNSTABLE MA 02668 6/19/13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 2/19/02 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate�on site plan): Depth below grade: 2 feet feet Material of construction:. ❑ cast iron 0 40 PVC ❑ other(explain): Distance from private water supply well or suction line. 115 feet from neighboring well feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 1 foot 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: 8 foot 6 inches 4 foot 10 inches Sludge depth: 2 inches t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form . Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 142 COACHMAN LANE Property Address BETH WARNER 181 B HUMMOCK POND ROAD NANTUCKET MA 02554 Owner Owner's Name information is required for every W BARNSTABLE MA 02668 6/19/13 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 Winches Scum thickness 2 inches Distance from top of scum to top of outlet tee or baffle 6 inches Distance from bottom of scum to bottom of outlet.tee or baffle 12 inches How were dimensions determined? sludge judge Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): no leakage 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•09108 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 142 COACHMAN LANE Property Address BETH WARNER 181 B HUMMOCK POND ROAD NANTUCKET MA 02554 Owner Owner's Name information is required for every W BARNSTABLE MA 02668 6/19/13 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•09M Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form . a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments y� 142 COACHMAN LANE Property Address BETH WARNER 181 B HUMMOCK POND ROAD NANTUCKET MA 02554 Owner Owner's Name information is required for every W BARNSTABLE MA 02668 6/19/13 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert . 0 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 leakage 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 f Commonwealth of Massachusetts . Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 142 COACHMAN LANE Property Address BETH WARNER 181 B HUMMOCK POND ROAD NANTUCKET MA 02554 Owner Owner's Name information is required for every W BARNSTABLE MA 02668_ 6/19/13 page. CityrFown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 4 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number:p ❑ 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.): dry Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ -No t5ins•09/08 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 142 COACHMAN LANE Property Address BETH WARNER 181 B HUMMOCK POND ROAD NANTUCKET MA 02554 Owner Owner's Name information is required for every W BARNSTABLE MA 02668 6/19/13 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.): 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 142 COACHMAN LANE Property Address BETH WARNER 181 B HUMMOCK POND ROAD NANTUCKET MA 02554 Owner Owner's Name information is required for every W BARNSTABLE MA 02668 6/19/13 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately Y t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 I Commonwealth of Massachusetts . Tithe 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments V•ry< 142 COACHMAN LANE Property Address BETH WARNER 181 B HUMMOCK POND ROAD NANTUCKET MA 02554 Owner Owner's Name information is required for every W BARNSTABLE MA 02668 6/19/13 page. City/Town 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: no ground water encountered 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: perc test 12/7/01 1 ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: pert test 12/7/01 Before filing this Inspection Report,:please see Report Completeness Checklist on next page. t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 142 COACHMAN LANE Property Address BETH WARNER 181 B HUMMOCK POND ROAD NANTUCKET MA 02554 Owner Owner's Name information is W BARNSTABLE MA 02668 6/19/13 required for every page. City/Town 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•M08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Town o1 Barnsfablc _ 4) Owartmof ufUuJ(h,5arctp,mud HAVIronmadul Sel'TIM 1 nv Public Iicnk to j}iylinn nate�i "' 357 Mb�t�ucet ]u Mr1 lQI�C t" „ • -� . MINIMA eXAMJ f7aac Scheduled r L-z,/0'��. j Time� +^n Fee Pd,• � Soil Suitabilitay.Assessment for Sewago.Disposal P<rfwa,eJ Uy:_, G WlaitaM I)y ilea v.(f' _ t,wnlal Adbon r�wv, mug '"•1;%Wyk-T�I Vu r, W'NG� �l,.($. �4Z t:.o.At�a A'VVrJ t.,�J, ,• Addrme VJ, !W9 OUQ I 4J , Auu.w'.Yt.y/Yy N: a Gn&tmm'sHmIc Zr)t wt �k 'F �h1h I N NUWCONSTRUG710N mPrAfk • i Ufhlamcer 11am; Opo Walrr Dody R rWtiela Wal A7ra n I)tbAh>R Wetm Wall 5k�' t,,n Urtinp Way I.M. 0 Mur n SKETCH:(suast nwm%dfpwn,irne rriai,axed IacatRuu n(tat haler t pm)eats,is"eeAttnde bt pracbalty a holes) ! L�l a r� z�l,o� N �Hrt� eA-Ay' , W 1J d Parret maiuid(acvluelcl„!�fiJ'L�'''f�� Ucpt6 ti tl�mvt_,��ZabYr ,... ..-- .. Ikpth to Qttwndrralrr.SYandina yleter to]Iola �/�1q" Wceaiae rrtmm fit Pecs Eellrrded9es.oeJllleb0rvamtlrrala A11,4 _ hit" t�sad; bgdh Okwo4,movi� ng imT-hole: ,M t W W.aB mlPmiae..,.._ _.Ua Dvibte+►eq fwrnafdanlube.lmla" _ Ic QL wllwelerAtUwemenf n. j 7I tii1 ,4ndraWcN1_. AuAIIA01111;__,, Index Well _w- Adj.l'n1Ur� _A14Groondaaterte.el,_- alt 1 itn Hate .t!'-A O 00 H / t �,+_ _ TLm L t t �• 10 ucrdh of rem SI.•1Ymyoah7{me(� Q:0O ThaaW-In rJJ10SAe - End Pre-jag �l tii[1U Role Mlnllmdt •!Z,. be�:n�r\ Shr 3o11a4i1hY AreWlOhwd; $ e rrwsd�• •-•�•••.` 9kc Yni(odl�_,__,_„�. AAd"ahtrM 7astlrg tla=dad(YR•t) /�" OdfliNA;MIN mew1h Dividan Obaervailttn(fole nata To Ue Couipfe(ed an Upcic Cape; Aoalicam V VII LJ 4ViJ iVVI I I V111•VI"lIV 1J1 IILr'IL 111 1JVVIJVV VV-I IV ./f..IV w..� fn.a .� v TO14'N OFBAPUNSTABLF, �.cr LOCATION I :.&Pj _ SEWAGE a Q8Q.,2-2�f-7 VILLAGI"s_W E< 1'" 'f�eLA�����4�' ASSESSOR'S MAP& LOT J_4Z;- lNSTAUER'S NAME&PHONE N�ar,�t^yt��. i�-�t��� _ �'��'�'-�► � SEPTIC TANK CAPACITY LLACIiING FACILITY: (type) ev-) Centio (size) 39 NO.OF BEDROOMS BUILDER OR OWNER / •� iy;c7 PERM17 DATE: y`6 _COMPLIANCE UAn: "!t—o Separation Distance Between the: Maxunuin Adjuster:Cirvuris lwatet'fable to dw Bottom of caching Faviiity Feet Private Water Supply Well and Leaching Facility (If any weals exist on site or within 200 feet of leaching faciUry) Feet 1 Edge of Wetland and beaching Facility (if any wctl4nds exist within 300 feet of Ieach.ing facillry) Feet Furnished by i -7T `f U 0 D • r i Town of Barnstable Board of ifealth 200 Main Street,Hyaamis MA 02601 Ottlx: 508.862.4644 Sinn(Y.82*U. FAX: 509-790-(i304 4u=er IS.tufn=,MSPH Waync.+Hier,M.D. Januar/25, 2002 Mr. Arne H. Ojala, P.E., PLS Down Cape Engineering, Inc. 939 Main Street, Route 6A Yarmouthport, MA 02675 LRE: 142 Coachman Lane,West Barnstable Dear Mr, Ojala, You are granted a variance on behalf of your client, Donald Zick, to construct an onsite sewage disposal system at 142 Coachman Lane, West Barnstable. The variance granted is as faiiows: PART XIV SE Y, 2.00: The soil absorption system will be located only 115 feet away from the neighbor's well, in lieu of the 150 feet minimum separation distance required. The Variance is granted with the following conditions: (1) No more than three (3) bedrooms maximum are authorized at this property. Dens, study rooms, offices, finished attics, sleeping lofts, and similar-type rooms are considered "bedrooms" according to the MA Department of Environmental Protection. (2) The epplirrant shall record.a property worded deed restriction, signed by the owner cif the property, at the Barnstable County Registry of Deeds restricting the property to three (3) bedrooms maximum.. A copy of the recorded deed restriction shall be submitted to the Health Agent prior to obtaining a disposal works construction permit. (3) The septic system shall be installed in strict accordance with the engineered plans dated December 14, 2001_ �t my `��d�.-t? j"? V G+1►f' 6t�i L� 1 �;*..�t p� 1���/! 2 THE COMMONWEALTH OF MASSACHVSSMS einrcrco to eoaww.,v ✓�� PUBLIC HEALTH DIVISION-TOWN OF BARNSTABLE.MASSACHUSETTS Y� 2PPIttation for Miopaal 6potem carjgtruttfuri permit Applicuion fur a Pemit tD Ccrlavi ()()Rep&( )lJpgrade( )Abartdrtn( ) C(Ampbe System C'Mv)daLjt f_.utngsnGata I.t.uwelvu.ld,arscs,71 n(No. / 2 CD�Ch"AtA'rV (dIv!'- :ht t Naar,,AdeAai an17f:,Na �� � 1 Aes»or's?,Lip/Pan`cl '.pilr✓d Zlt.� 1xi _ /dZ or�l++^wh cue w. —rua,dtu's Name*npt tC9B irsl 71t.lYn. J c76 7711410 aw 10 w'%Noma.AMmo add Tot Na /iSSvRAN rd�alfgTiero n 4n dny;em.,y,�y svr/tra,•v ),'�,, ` Sit r+,o,M Yr. lypa rtf RWTdiagt -- Dwelling Nu of 9edrtmma 3 _ Lot Side}¢z tq,to Gaulr:gc i)Ljwlnr fW) thlscr Type of Building NO.of PetgoorP _-Sbuwm, f afemnA( ) OthcrFiktcurs_ �77 _ Desiypa Plow SalJou per day. Caiculuted akily flaw 3 3 �� g:tllurss. Plan Date-4arm?WK IL2ee1_Numb=ofsheets._1._ _.. Revisiun Dam Tide t. ?'e t' ,f,Tc i7✓s., _ Sizo of Septic 11tMk , jam; v aft Type of S,A S. Dcuriptiou or Csil D- -7-- � 1 SUMVISE 1,c ��_�x scud•u� 40 - INBTN.L4 N AND CERTIFY IN WAITING YHE sirlcr Natostit utliepaira er Aiteratitoaa(Anaxwr windy applicable)�_/, j,.,, — ��_. relJ � Date last ions Wdl A fri+amtat: The insdfflli ed agrees IV 9MUZO dre Cnoxtrlp;tine and mainmviince otthe afaic&scribirw ou., to sewage dlSpowl spiem in auur-antic with the pruvisions of Tidd 5 of Lhe F.nvi4vameatd Cndc and aut to place the syrtout is uperu dan until a t:mfi- cax of Compliattas 1>ae heon i d of lisakh. Appiic ution Approved by _ _ Date' Applicarloa Diaappmved for Un follnwing rtw--s Pmttut No.— Da 1.' �._ Uric l"Ded '� y THE COMMONWEALTH OF MAMACHUSETT'S BARNSTABLE, MASSACHUSETTS QCertifitate of (Clumpffamt MS 1S M CFiRTIFY,&ft OA-Silt Sewsgc I)trpOsal System Coasttuctdd(X)Ropoinxl A1.ujWWW( )by at . [/ ,. ;h, , [a n p has heart construe t.^d a aa:uriksace with tho ptnvisioas d'15110 5 and Ibe Jbr ihepnaal System ConstAlc6un Permit No. iu J•v'/ —dated U r Ioatalha Designer_ The isaaaace of this permit SU11 tut be conatruw1 m a guarantee Iha the syammytdi u fun coon ddci ed. Data l totlp'1 impetlur lr..�. f :T THE COMMONWEALTH OF I,AASSACH'USMS PUBLIC HEALTH DIVISION•BARNSTABLE,MASSACHUSETTS 32*004( Opstezn CansIrWion jPerind Pur:ttitaion is hereby granted to t"nnttruct )Re/pair(, j i./pgr uio( )Abaaduu( ) sysrcrrt luL;ued at /��� {'aa 1 �.,,:•. r--�"n� .;Iw:r►deacrtbed in the ahcsve Appacaldno for lei poxal Srvtam c:ontxr.-den Foul it.Ile 4mliennt reo gaia)a his/her duty to u)trtplY with Title 5 and the following looal pruviaicm err spataai cottditiAns. ProYiJdd:C011artDC601a must ha compietrd within tltree yews of the date of t1U, t, Date: yl�U 1- _Approved by. .8�L' - Commonwealth of Massachusetts Form Title 5 official Inspection • Subsurface Sewage Disposal System Form Not for Voluntary Assessments 01-C/ e F): rty Address . L9 ZZ/ Owner owner's N,1 information is o Zip o e Date of Inspectio required for A0.X Stot Zlip�oke t, every page. City/Town ubmitted on this form. Inspection forms may not be altered in any Inspection results must be s way. important: A. General Information When filling out forms on the computer,use Inspector: only the tab key to move your Michael DeDecko cursor-do not Name of Inspector use the return Compass go ration key, Company Name rab P.O. Box 2384 Company—Address Ma 02649 Mash pee State Zip Code rcrmn City/Town 508-221- 5003 License Number Telephone Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: R Conditionally Passes EJ Fails Passes Needs Further Evaluation py,the Local Approving Authority Lo I M !7-> Ln 0 Date Inspector's Signature The sys tem 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 DER 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. Title 5 Official inspection Form:subsurface Sewage Disposal System-Page i of 15 blank form•08/06 Commonwealth of Massachusetts , ��^A^N�� �� ~�*~��N N���������~��D���� ����N°N�M� N ��Nw= �� ���NNU��N�wN wmm~m���������~^ m Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments , -'l_l�~_ ---------------.......... — -- - - pmpontyAdunaso Owner Owner's own="'~~^~ in,unnationi's �L��I ,����z��� _-��� required for -'---�- ���-- ��Cnuo o�eov|nopo��n � every page. ~'r'~^'' � � B. Certification (cont.) � � Inspection Summary:� Check /\B.C.D orE/always complete all of Section D � � � AJ Passes: � 7"�/ | hawa not found any information which indicates that any of the failure criteria described � �~ in31OCK0R15.3O3orin31OCK8R15.3O4 exist. Any failure criteria not evaluated are � indicated below. � Comments: B\ System Condition ally Passes: �� one ornnopesystmnnoon�ponentsoodeonhbed \n the^Cond�ona\ Pass" seot�nneed tobe �� replacedorre^ainad. Thaovstom. upnncomp|etionofUlenep|aoennentorrepair. asapprovedbv the Board of Health, will pass. � Answer yes, no or not determined [Y. N. ND) in the E] for the following statements. If"not determined," please explain. The septic tank io metal and over 2O years old* orthe septic tank (whether metal or not) ia 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 bythe Board ofHealth. ^ A metal septic tank will pass inspection if it is structurally sound. not leaking and if Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: Observation ofsewage backup or break out cx high mtaUcvvator�va\ hlthad�thbuUonboxdue to broken orobs�VCted � or due hJa broken, settled or uneven distribution box. System will pass inspection if(with approval of Board ofHea\th): �l broken pipe(s) are replaced Fl obstruction is removed rme5 Official mnoomm �nro, uuo,oxm ax�m000/"nvsa/u'*am'pan"2*`o monxm,m'o�s � � Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments pro�erty Address Owner Owner's Name information is .t - -- — --- -- . _. required for CitylTo n Slate Zip Code Date of Inspectio every page. B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ 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. Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 blank form•08106 Commonwealth of Massachusetts Title 5 Official Inspection Form R Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u� ..r- Property Address --------- - -------....—.------ Owner Owner's Name F {� information is required for �11.t� iU __ -- - -- - - C�if{/Town State Zip Code Date of nspection every page. Y 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 Eltj/ Static liquid level in the distribution box above outlet invert due to an overloaded 15 or clogged SAS or cesspool ❑ Liquid depth in cesspool is less than 6" below invert or available volume is less than '/z day flow ❑ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ P� 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. Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 blank form•08106 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments Property Address Owner Owner's,.Name 4-1 information is required for every page. City/Town State Zip Code -6 ai>,-�6-f�l!-ns pecti o n B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No F-I E�� Any portion of a cesspool or privy is within a Zone I of a public well. E] [9"/ Any portion of a cesspool or privy is within 50 feet of a private water supply well. E] 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- El U2/ The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CIVIR 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 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 D M the system is within 400 feet of a surface drinking water supply El 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 \f you have answered "vem"bJ any qU8sUOnin8eCt� nO OEUl� aV5t� iScOnSidereda significant threat, oronavvanad ^yee^ inSection D above the large system has failed. The owner or operator o!any large �yntornconsidered os�':'''��cant threat under Section EorfaUed under GeobonDshaU upgrade the � � /^abann \n accordance vviMn31OCW1R15.3O4. Theeya�anno�n�r should Contact the appropriate regional office of the Department. Title 5 Official Inspection Form:Subsurface Sewage Disposal system'Page 5m`5 ' Commonwealth of Massachusetts Title 5 Official Inspection Form x Subsurface Sewage:Disposal System Form Not for Voluntary Assessments Property Address Owner Owner's Name information is ( ` \ . J. . .�-r required for �t _.....—___._. ..__.__. every page. City/TownState Zip Code Date of Inspection ms 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 ❑ [Vj�' 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? ❑ 2 Have large volumes of water been introduced to the system recently or as part of this inspection? El available as built plans of the system obtained and examined? (If they were not available note as N/A) ❑ 0 Was the facility or dwelling inspected for signs of sewage back up? P/ ❑ 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)] blank form•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal Syslem•Page 6 of 15 [� ' Commonwealth of Massachusetts Title 5 official Inspection Form ssessments Not for Voluntary A Subsurface Sewage Disposal System Form Property Address -- -- - o~ne, wriers Name information is __-_' -���3 required for +�^=�-^--------� cx�� z/puno� Date"' ^~~~~— ev°�page. ~-'��—' D. System Information Residential Flow Conditions: -����---- Number of bedrooms (aotuaV: ---------- Number cf bedrooms (daeign): � DESIGN flow based on31OCK8R15.2O3 (for example: 11Dgpdx#nfbedroonna): -----------' Number of current residents: | F� Yes �� No Does residence have a garbage grinder? �~ / \s laundry onosapa ^ rateoevvagesys�em?Ufymmoeporatoinspeotionrequiredl Yes No �l Yes 2' No Laundry system inspected? Yes Soaaona\ uea? --�__, �_`___'_ Water meter readings, \f available (last 2 years usage (gpd)\: � | | Yes Nr No Sump pump? Last date ofoccupancy: ~~~ | � Commercial/industrial Flow Conditions: � Type ofEstablishment: Design flow (based nn81OCMR152O3): Mons per day(gpu) Basis of design flow (oeoto/paroono/sq.ft.. etc.): -----�� Yes No Grease trap present? Yes �l No Industrial vvasteholding tank present? �_ __ Yes �� NO � Non-sanitary vvontadischarged to the TiUe5system? �� �� Water meter readings, ifavailable: � Last date ofoccupancy/use: Date | Other(describe): rue:offi��m�e�w`r�m:ou�u�c xm" �m����x'mm"'pn�rm,o blank form'vw06 L _ Commonwealth of Massachusetts rS� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments Property Address ri Owner Owner's�,ame information is 0 U& required for ectii.� .- � W-14� _S_t�a_t_ Zip Code Date of Insp every page. city[Town 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 0 maintenance contract(to be obtained from system owner) F� Tight tank. Attach a copy of the DEP approval. D Other(describe): Approximate age of all components, date ins.talled (if known) and source of information: Were sewage odors detected when arriving at the site? El Yes WNo Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 15 blank form-08/06 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal SystemNot for Voluntary Assessments Form Property Address Owner Owner's Name information is required for 6�Jt- State Zip Code 0 Inspection! every page. City/Town D. System Information (cont.) Building Sewer (locate on site plan): Depth below grade: feet Material of construction: ❑ cast iron 9/40 PVC El other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): L) Septic Tank (locate on site plan): Depth below grade: feet Material of construction: oncrete ❑ metal ❑ fiberglass El polyethylene ❑ other (explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes El No ----------------------------------------------------------------------------------------------------------------- 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 Vl Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Title 5 Official Inspection Form:Subsurface Sewage Disposal system-Page 9 of 15 blank form-oa/06 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments Property Address Owner information is Owner's Name required for state Zip Code Date of Inspection every page. City/Town 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.): 10 UiL t Grease Trap (locate on site plan): Depth below grade: feet Material of construction: R concrete metal El fiberglass ❑ polyethylene E] 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 El metal ❑ fiberglass ❑ polyethylene E] other(explain): Title 5 Official Inspection Form Subsurface Sewage Disposal System-Page 10 of 15 blank form-06106 Commonwealth Titl��~^�B�� �� ��^�����~~��N N��������°��~���� ����N~��� e �� ��nNN8��N="� mw .�~�r~=�~�o=~° � Form � Subsu�aceSmw/ageDisposal SymtennFormn - NotforVo|un�oryAaaesannents ( ------------'----------- -' — - Property Address Owner Owner's Name / information is required for State-- Zip Code - Date o,Inspection ^ every page. City/Town D. System Information (cont.) Tight or Holding Tank (cont.) Dimensions: -------------'-' - - Capacity: gallons � Design Flow: Alarm present: 0 Yes E] No Alarm level: Alarm in working order El Yes No Date of last pumping: Date Comments (condition of alarm and float switches, etcj: �� �� °A�ochcopy of current punnpinQcontract(requinad). \o copy a�aohed? �� Yes �� No Distribution Box (if present must be opened) (locate on site p|an\: Depth of liquid level above outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out nf box, etu.): | Pump Chamber(locate on site p\an\: Pumps |n working ondec �� Yes El No | Alarms in working order: ���� Yea ���� No � Title o Official Inspection Form:Subsurface Sewage Disposal System'Page``m`u blank form'om06 Commonwealth of Massachusetts - Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form - Not for Voluntary Assessments P Address rop.� owner owner's Name tt cc7� information is � J { u�US J W-1 :- required for - - State Zip Code Date of Inspection every page. city/Town 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: �] leaching pits number: ^/ leaching chambers number: l� leaching galleries number: leaching trenches number, length: leaching fields number, dimensions: 7 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.): � d , tti� �� -� - f-.bV 1 Title 5 official Inspection Form:Subsurface Sewage Disposal system-Page 12 of 15 blank form-08/06 Commonwealth of Massachusetts Title 5 Official Inspection Form IR , Subsurface Sewage Disposal System Form Not for Voluntary Assessments Prole y ldcr�Ss Owner ner's Name t�+ 1L� information is Ow ^' required for c State Zip Code Date of Inspection' every page. City/Town 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 grouncwater inflow ❑ Yes ❑ No Comments (note ccndition 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.): Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 blank form•08/06 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments Property Address —.......... Owner Owner's Name information is A State ft- required for Zip Code -Date of I spec�Wn every page. City/Town 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. ------------ o it it -A3-33 �3- �31 3 Title 5 Official inspection Form:Subsurface Sewage Disposal System-Page 14 of 15 blank form-06/06 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments t S v Property Address __Zs s: __.-.._ ____ -- ---- __—. - -- _- - - - . Owner Owner's Name information is Vv� _h required for (ll,�s �'�.t.1� 1�u .\'.� _ ........ t every page. CitylTown Stat Zip Code Date o Inspection D. System Information (cont.) Site Exam: heck Slope Surface water [:C eck cellar Shallow wells h to round water: Estimated depth g feet Please indicate all methods used to determine the high ground water elevation: ;7 Obtained from system design plans on record 6 If checked, date of design plan reviewed: pate ❑ 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: Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 15 blank form•06/06 Bk 14797 P090 112425 02-08-2002 d 08 = 06u DEED RESTRICTION WHEREAS, Donald P. Zick and Ana J. Zick of 142 Coachman Lane, West Barnstable, MA("Owners") are the owners of 142 Coachman Lane, West Barnstable, MA and being shown as Lot 8 on a plan recorded in Barnstable County Registry of Deeds in Plan Book 384, Page 56; WHEREAS, Owners have agreed with the Town of Barnstable Board of Health to a restriction as to the number of bedrooms which can be included in the home built on said lot as a pre-condition to obtaining a variance from the 310 CMR 15.214 State Environmental Code, Title V, Minimum Requirements for the Subsurface Disposal of Sanitary Sewage. WHEREAS, the Town of Barnstable Board of Health as a pre-condition to granting the variance from 310 CMR 15.214, State Environmental Code, Title V, Minimum Requirements for the Subsurface Disposal of Sanitary Sewage, is requiring that the agreement for the restriction on the number of bedrooms in any house constructed on the lot be put on record with the Barnstable County Registry of Deeds by recording this document. NOW THEREFORE, Owners do hereby place the following restriction on his above- referenced land in accordance with their agreement with the Town of Barnstable Board of Health, which restriction shall run with the land and be binding upon all successors in title: Owners do hereby agree that the constructed house shall contain no more than Three (3) bedrooms. Owners do hereby agree that this shall be permanent deed restriction affecting the property located at 142 Coachman Lane, West Barnstable, MA, and being shown Lot 8 on the plan recorded in Plan Book 384, Page 56. 1 4L For title deed: recorded in Book 4737 Page 338. Executed as a sealed instrument this day of February, 2002. Donald P. Zick �na J. Zt) d COMMONWEALTH OF MASSACHUSETTS Barnstable, ss February , 2002 Then personally appeared the above named Donald P. Zick and Ana J. Zick and acknowledged the foregoing to be their free act and deed, before me� Not ... t c MyPnOission.expires: JOHN CLARK STEPHENSON Notary Public Commonwealth of Massachusetts My Commission Expires November 29,2007 20Ja-00I , Vol�1,�� �i�. V(F�n�P 12, No. `7 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Z(ppYtcatton for 30t5pool bpgtem Com5truction Vermtt Application for a Permit to Construct()<)Repair( )Upgrade( )Abandon( ) El Complete System El Individual Components Location Address or Lot No. / Z <fo,*d#1nA-/V 44 Ve- Owner's Name,Address and Tel.No. 0Oh'J'/ Z./C< Assessor's Map/Parcel J / Z 9 /¢'Z C pcc.d_Wn q h LN Installer's Name,Address,and Tel.No. S"O&771741 O Designer's Name,Address and Tel.No. ���tiRRMC� � Col✓ct?!a t9 7�W4 Ca{ae e-t? cat #—A .J— Type of Building: Dwelling No.of Bedrooms 3 Lot Size Ido�7q.ft. Garbage Grinder eje)) Other Type of Building !e 66LoA No.of Persons Showers(,7\) Cafeteria( ) Other Fixtures Design Flow 33 v gallons per day. Calculated daily flow 3 3 d gallons. Plan Date `6C,--,Mbe'K 1 Z 1.061 Number of sheets J Revision Date Title Z T/e S 5,70 AZA,7 Size of Septic Tank X % 100 d Type of S.A.S. VISE Description of Soil, O'3' , l-"c -to Styr IPA t 4t� /M eaj-.v„* Sqo%. INSTALLATION AND CERTIFY IN WRITING THE SYSTEM WAS INUALLEDINSTRICT ACCORDANCE Nature of Repairs or Alterations(Answer when applicable) Ncshl en 44•r Date last inspected: Agreement: The undersigned agrees io ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been is uqd b this Board of Health. Signed Date Application Approved by �. Date Application Disapproved for the following reasons Permit No. - 0 Date Issued �, '� No: U� —. V P ( (/� V/fin�P�l >�L r t G Fee �" a 4 � '° "� I Entered in computer: v / • �. i x, THE COMMONWEALTH OF MASSACHUSETTS p PUBLIC HEALTH DIVISION-.TOWN OF BARNSTABLES MASSACHUSETTS • fication for ;h5po0al *pztem Construction Permit Application for a Permit to Construct(x)Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. / <1Q,4 c11-t1n ,,%J 4A.,VE- 'Owner's Name,Address and Tel.No. 70itk/� Z.r K Assessor'sMap/Parcel C' /4f•Z, . p _ Qy L,V• /3l 2 9 w. CAM Installer's Name,Address,and Tel.No. 5_oEf 77174-I O Designer's Name,Address and Tel.No. lfSSvRRroC� L�'xCu✓gTior� 7vwn C CA tow CP�107e•_riof r Gr/r/�iun-r /�/�+ er °(3�f r'hA�T ST• ' ,r w Type of Building: Dwelling No.of Bedrooms 3 Lot Size 067 LYsq.ft. Garbage Grinder Other Type of Building o% �i�,a,/� No.of Persons 4 Showers Cafeteria( ) Other Fixtures F Design Flow * 3 y gallons per day. Calculated daily flow 3 3 d gallons. ;Plan Date 1>e Cc m beK 1 Z 1 eo I Number of sheets / Revision Date Title _Z 7-1 e ,S' .S,TO P&n Size of Septic;Tank Xr5%r 1v0 Type of S.A.S. Lfq ehipl mb-.r Description of Soil.: O-N Laa.wy S4-0 a 1 44 m e1"v— Nature of Repairs or Alterations(Answer when applicable) XV/_`� 64e/+•,� u I /ate e /`A L Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system p.. in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation-until a Certifi- cate of Compliance has been issueA bv this Board of Health. Signed Date Z-4-o z- i y Application Approved by - �`'• Date ?` —U r Application Disapproved for the following reasons Permit No. )o o-J. - 00 1 Date Issued 2- m THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed X Repaired ( )Upgraded( ) Abandoned( )by at /1l.2 co a c 4,Man L 01 01 e has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. a W a V`/7 dated 02 ` Installer Designer The issuance of this permit shall not be construed as a guarantee that the system,will ( " 1 fu ction a desi�d. Date l�� Inspectorl / n . V No. 2 U Qi/7 Fee 5v — THE COMMONWEA4THr,OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS ligogal *pztem Conotruction Permit Permission is hereby granted to Construct )Repair( )Upgrade( )Abandon( ) System located at 1 1-/.2 Cw t H rn H, L-A, and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Construction must be completed within three years of the date of this Date: Approved by Aits lt � jtjL— TOWN OF:BARNSTABLE Ec. LOCATION Ava C-DA IM J-/ SEWAGE # 90 VILLAGE W EC;T` BAR Pl31;-% 4P3ki . ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. �iCL/' 'l IJ7 3Pa ]_-� SEPTIC TANK CAPACITY LEACHING FACILITY: (type) .YOO Clilkl1 r3 (size) t. NO.OF BEDROOMS BUILDER OR OWNER % off PERMITDATE: - -b } COMPLIANCE DATE: -jti -0 Separation Distance Between the: Maximum Leaching Adjusted Groundwater Table to the Bottom of� g 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 wetlinds.exist within 300 feet of leaching facility) Feet Furnished by I i I C� 0 t� tel.(508)362-4541 .939 main street rt 6a • fax(508)362-9880 yarmouth port mass 02675 down Cape en��neering civil engineers& land surveyors structural design Arne H.Ojala P.E., P.L.S. Timothy H.Covell, P.L.S. land court Daniel A.Ojala,P.L.S. surveys February 20, 2002 site planning sewage system Thomas McKean, R.S. designs Barnstable Board of Health - 367 Main Street inspections Hyannis, MA 02601 permits Re; 142 Coachman Lane, W. Barnstable Dear Tom:. Down Cape Engineering, Inc. performed an inspection of the k newly constructed septic system at the above-referenced location. The septic system is hereby certified to be installed in substantial compliance with the approved plan. If you have any questions, please do not hesitate to call me. . Yours truly, Arne H. Ojala, PE, PLS Down Cape Engineering, Inc. cc: Donald Zick Town of Barnstable P f1 l d a Department of Healtgt,Safety,and Environmental Services Public Hetaith Division Date 12 0 367 Main Slreet,,Ilyannis MA 26i .'� � � i..0 •.r ova �t'...I.j.,.: MARNNTAULK ►� Date Scheduled rZoo.7 O ( Time U, " Fee Pd. Soil Suitability Assessinent for Sewage Disposal Performed By: VIA V Witnessed By: i J V C J I!nn 77J'� I t ... ' t: <:'rG:<:E::> >><;i:: 5<:::i:i ::»?:<:::::<>::::[:>< V. ' 1L: lr..Z.1.�1.1.. 1i.11't. '.... ..... .............._................................. i Location Address Owner's Name 1 y� �vu�� ►�� 1��-� . Jam. pNA Z\c-IL- Address f 1 yz c©,gc"�lJ �, - _ 1 U7. l�rn�ns���Q w ,,,� Assero�'sMap/Paecel: Engineer's Name li/"1/'� � Sl�o NEW CONSTRUCTION REPAIR Telephone# "x'$ _ 3t Z^ y 7" Land Use Slopes(%)_ 115 6� - Surface Stonesy� Distances from: Open Water Body ft Possible Wet Area ft Drinking Water Well �}" l t ft Drainage Way ft Property Line ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&Pere tests,locale wetlands in proximity to holes) (,CT �- tip � M i 4 Parent material(geologic) M04(Zt)1JC Depth to Bedrock Depth to Groundwater: Standing Water In bole:_ f�I 1A Weeping from Pit race N1A Estimated Seasonal High Groundwater ..:..........:..::..,:.:::::....,.........,.,...,...<......:..,,..;,....:...,..,.;.....:..::..:.::........,.:.:.:..,;..,......,.;...:..,;,:......,;....... :......,..............:.;,....,:;;..,..,,.....:z<za:»•.!::'t>:.::::'^.':s>::»:::;: ;:<.::.::;:;:.;:;:>:::.:: yy��yy--1try•+��--t+��yy **��y(��r�iT �q yy�� yy�yy yy� �+ �y Y :::1... 1[. :L~ . �1\ ., 1, ....:::.:... .:::.::::.,• Method Used: _ ��q� Depth Observed standing in obs.hole: _ in. Depth to soil mottles:� G-(ZO P _�//Y Depth to weeping from side of obs.hole: in. Groundwater Adjustment +-Index Well N _•_•_ -Reading Dote: Index Well level...__ Adj.factor Adj.Groundwater Level ::rttn O�Y:.'BLS'C.:::::::.::::::::...:a.::.. .::::::::.:.�::.�:1::�,.:;::::: Observation -)-� Hole N i !._ �-' I t► ...) Time at 9„ L Depth of Pere "J O `,1' � �© Time et 6" ) y _ V-6.�Time!t7 V M�!� �0�L Slert Prc-soak Time Q o ( ) End Pre-soak Rate Mln.Anch Site Suitability Assessment: Site Passed Silt railed: Additional Testing Needed(YIN) Original: Public Health,Division Observation Hole Data To Be Completed on Back j Cony: Applicant rl 1— .;:.:...::....:..,.;....:...... :.:y::;y, :.,;;;:<>.:>:::z<:>;::>z:::a4F::;:;•,...:;;•::<:<''<:>:<i<::>:«8 >:<z«:[:i2q`?>::;:>:>:<:>» »:< Ix Depth from Soil horizon Soil Texluro Soil Color Soil Other Surface(in.) (USDA) (Munseil) Mottling (Structure,Stones,Boulderes. % oyr2-'411 . 6- M/r- a I3S�1�,YATT�N:.�-IQ.)�� Depth from Soil Norizon Soil Texture Soil Color Soil 011rcr Surface(In.) (USDA) (Mansell) Molding (Structure,Stones,Boulderes. i I $.. Al Depth from Solt Ftorizon Soil Texture Soil Color Soil Other i Surface(in.) (USDA) (Munsell) Mollling (Structure,Stones,Boulderes. a i � I t ................................................ ::>:OBSI;R`SAT.I.ON:BOLL':.LfJ;G:.>;:.:::::: :«.::; ::::p.:.::::::: Dcplh from SoilNorizon Soil Texture-': Soil Color, Soif.,.:,t Other .. Surfaca(in.) (USDA) --(Munsell)'.. Mottling' ($t{uctu�c;Slopes Doulderes _. e i .,Flood Insurance Rate Max / Above 500 year flood boundary No Yes y/ AA5) ) �i2 j LE lZ CGS , . C9 �Z z10 O �� `�' 1 � � 1 •'14�1'.',. I,.� � �, t I t' J{ E tx .?Jq� � pANIEL A. OJALA COMMONWEALTH OF MASSACHUSEITS PROFESSIONAL LAND SURVEYOR 1S.E, Town of Barnstable " Board of Health 200 Main Street,.Hyannis MA 02601 _ Office:.508-862-4644 Susan G.Rask,R.S. FAX: 508-790-6304 Sumner.Kaufman,MSPH Wayne Miller,M.D. January 25, 2002 Mr. Arne H. Ojala, P.E., PLS Down Cape Engineering, Inc. 939 Main Street, Route 6A Yarmouthport, MA 02675 RE: 142 Coachman Lane, West Barnstable Dear Mr. Ojala, You are granted a variance on behalf of your client, Donald. Zick, to construct an onsite sewage disposal system at 142 Coachman Lane, West Barnstable. The variance granted is as follows: PART XIV SECT. 2.00: The soil absorption system will be located only 115 feet away from the neighbor's well, in lieu of the 150 feet minimum separation distance required. The variance is granted with the following conditions: (1) No more than three (3) bedrooms maximum are authorized at this property. Dens, study rooms, offices, finished attics, sleeping lofts, and similar-type rooms are considered "bedrooms" according to the MA Department of Environmental Protection. (2) The applicant.shall record a properly worded deed restriction, signed by the owner of the property, at the Barnstable County Registry of Deeds restricting the property to three (3) bedrooms maximum. A copy of the recorded deed restriction shall be submitted to the Health Agent prior to obtaining a disposal works construction permit. (3) The septic system shall be installed in strict accordance with the engineered plans dated December 14, 2001. Ojala3 r (4) The designing engineer shall supervise the construction of the onsite sewage disposal system and shall certify in writing to the Board of Health that the system was installed in substantial compliance with the submitted plans dated December 14, 2001. This variance is granted because physical constraints at the site severely restrict the location of a soil absorption system due to the extreme topography and the presence of other wells in the area. It is the opinion of.this Board that the proposed new septic system is designed to meet the maximum feasible compliance standards contained within the State Environmental Code, Title V. Sincerely yours, I� Susan G. RaSK, R.S. Chairperson l jalO I t l ECG ?EId ❑D a7q3Hn-1 3s;�o J ?6Et'SE?82S 00 :30 0p THE 1p� C9A'arnstablte DATE.: FEE: EARNBraBLE. Mass. 059. ��� REC. BY �f0 MA't s 'Town o SCHED. DATE: Board of Health 367 Main Street, Hyannis MA 02601 Office: 508-862-4644 Susan G.Rask,R.S. FAX: 508-790-6304 Sumner Kaufman,M.S.P.H. Ralph A.Murphy,M.D. VARIAINCE REQUEST FORM LOCATION Property Address: - (�Ae 4-14 ry,,a� Assessor's Map and Parcel Number: 5k Size of Lot: Wetlands Within 300 Ft. Yes Business Name: No_� Subdivision Name: APPLICANT'S NAME: b-,"44•o 2—L4+_ Phone Did the owner of the property authorize you to represent him or her? Yes YL No PROPERTY OWNER'S NAME CONTACT PERSON Name: -D014 4Ly, f /DNA Z.l[,}1-- Name: 5A2A1.0 QS4." -Mo Address: 1 `t y � l►.�4a.-1 1--`I. Address: Phone: ,��� q q Phone: VARIANCE FROM REGULATION(List Reg.) REASON FOR VARIANCE(May attach if more space needed) �.l )C l 1 �i c•LZ o rs 1�— S� L��;2. ',AEL.L— Tn A-4 NATURE OF WORK: House Addition ❑ House Renovation ❑ Repair of Failed Septic System Checklist(to be completed by office staff-person receiving variance request application) _ Four(4)copies of the completed variance request form _ Four(4)copies of engineered plan submitted(e.g.septic system plans) _ Four(4)copies of labeied dimensional floor pians suomiaed(e.g.house plans or restaurant kitchen plans) _ Signed letter stating that the property owner authorized you to represent him/her for this request _ Applicant understands that the abutters must be notified by certified mail at least ten days prior to meeting date at applicant's expense (for Title V and/or local sewage regulation variances only _ Full menu submitted(for-.tease trap variance requests only) _ Variance request application fee collected(no fee for lifeguard modification renewals,grease trap variance renewals(same owner/leasee only],outside dining variance renewals(same ownerileasee only],and variances to repair failed sewage disposal systems (only if no expansion to the building proposed]) Variance request submitted at least 15 days prior to meeting date VARIANCE APPROVED Susan G.Rask,R.S.,Chairman NOT APPROVED Sumner Kaufman,M.S.P.H. REASON FOR DISAPPROVAL Ralph A.Murphy,M.D. Q:/WP/VARIREQ tel.(508)362-4541 •939 main street rt 6a fax(508)362-9880 yarmouth port mass 02675 down cape engineering civil engineers& land surveyors structural design Arne H.Ojala P.E., P.L.S. Timothy H.Covell, P.L.S. land court Daniel A.Ojala, P.L.S. surveys December 13, 2001 Donald and Ana Zick site planning 142 Coachman Lane West Barnstable, MA 02668 sewage system designs Dear Mr. and Mrs. Zick: A public hearing has been scheduled for the Barnstable Board of inspections Health to take action on a request for a variance from a Barnstable Board of Health regulation for your failed septic system. The variance requested is as follows: permits Town of Barnstable Regulations: Proposed leach facility to be less than 150' to abutting well (35, variance requested) Said hearing will be held in the Town Hall_ conference room, 367 Main Street, Hyannis, January 23. 2002, at 7:00 pm. Please check with the Health Department to confirm date and time. Sincerely, Sarah B. Ojala Down Cape Engineering, Inc. cc: Abutters file Barnstable Board of Health tel.(508)362-4541 ,939 main street rt 6a fax(508)362-9880 yarmouth port mass 02675 Gown cape en�inee�ing civil engineers& land surveyors structural design it Arne H.Ojala P.E., P.L.S. Timothy H.Covell,P.L.S. land court December 13, 2001 Daniel A.Ojala,P.L.S. surveys Barnstable Board of Health site planning 367 Main Street Hyannis, MA 02601 Sewage system Re: 142 Coachman Lane, West Barnstable designs Dear Board Members: inspections The enclosed represents a variance filing for a septic repair for an existing (older) Title V septic system. No addition of habitable space is proposed. The following permits variance is requested: reduction in setback, proposed leaching facility to existing well, 150' to 115' (35' variance). No other variances are requested. Due to site constrictions(extreme topography and the presence of wells), a - variance is necessary to an abutting well. This abutting well is relatively new- being a new location because the original well which was at the rear of the property had failed. This well was installed at 108' off locus' leach pit. Now this leach pit has failed, and due to the requirement of Title V that no system be greater than 3' below grade(it is a DEP variance) and the severe slope of the lot, it would be extremely difficult if not impossible to install the system other than where it is shown on the enclosed plan. According to the GIS Groundwater Map, groundwater appears to be moving in an east-northeasterly direction,which would be away from this well. We have provided a 40 mil liner on the downhill side of the leach facility in order to mitigate any chance of breakout. We feel that by granting this variance, the same degree of environmental protection can be attained without the need for strict adherence to the Barnstable Regulation. Thank you for your consideration. Very truly yours, Arne H. Ojala,PE,PL Down Cape Engineering, Inc. M. Donald and Ana Zick �.�`. �ro1,�3NNa� tu3sn►nvssvp ONI dVV481V Slob ' /VJM3,ssv Jo oavos 311sviswav BKL Ao ►qi MIC 3N1 ✓lf3oNn 03V 3Wd O 7dLF �7�'d5 N3d0 ,I q 6S O''8 a e� a c� w e\J ..DD �dg5 16-T2 -w d �a e? 7d E 5• mn\ it -�dbq L_0 �titi sw \" © A pt� L o �4 �'4 d►' I yp 4� i yr'.B w i qq i •\ O � � e It v ti I\ n'0 � o o9r � M��l1r���•� hw�°j , ® t 1 4 w OM :� O � z :{r'•a �o one O , I 3 )rAb so S� &IJOV.?J e r C A \0 ti AA / V Cf \� �ti Ma�l.plf Noll / -vp_ZS�_N O KTJU-�N OF,:BARNSTABLE �. LOCATION CPACAIY�" ..C144/E SEWAGE # Qolo,2'01-17 ViLAGE U)F-<7r BAR 10;iAP5QF— ASSESSOR'S MAP &LOT Y INSTALLER'S NAME&PHONE NO. ✓f�CLfi �7 SEPTIC TANK CAPACITY , LEACHING FACILITY: (type) -00 C/-0-m O%r.Z(size) NO. OF BEDROOMS BUILDER OR OWNER PERMIT ATE: W-b COMPLIANCE DATE: 2_ 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 n c� n . -`L 0 C}A T 10Ns rcD�s .� � ' SEWAGE PERMIT NO. dT Coac-hd-1 A.) a- - 2-0 4 / VILLAGE ��1�, y�� )A S INST -A LLER'S NAME a ADDRESS e 1�Jr'>A1 rr d1.1 s 9 t� Q 0 U I L D E R OR OWNER` e n DATE PERMIT ISSUE-D DATE COMPLIANCE ISSUED N �� �,o T ^' -ten 7 i.. ;f No .4I.. F ..�1. �s.....�4 .. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ' . /./ ----------------OF.........: ApplirFatinn for Uiap.aii ai Work.5 Towi rurtiun 1hrmit Application is hereby made for a Permit to Construct (K) or Repair ( ) an Individual Sewage Disposal fp System at: a�.... r. ......... r:��T --------------------------- ............................---....:..._. ocation-Address or Lot No. .�i S.............•----............................ .........._....................................................................................... Owner Address .�UQd4.... ........................................................... Installer Address dType to ing Size Lot_.YYe®�_7.....Sq. feet U Dwelling—No. of Bedrooms ...........................:...Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building ............. No. of persons................_._..__._... Showers — Cafeteria aOther fixtures ---------------............................................................ W Design Flow................, _� ...................gallons per person per day. Total daily flow........ .........................gallons. WSeptic Tank—Liquid capacityJVCC2.gallons Length..........,...... Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area.................---sq. ft. Seepage Pit No....... Diameter-----ZO........ Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank / Percolation Test Results Performed by_��"��'... li PEk.. `! !4 G. S1a............... Date....._? � el. R.Y........ aTest Pit No. 1......�......minutes per inch Depth of Test Pit..... Depth to ground water...S!Q_-6�z.0_. Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Rai . ----------•-----------------------------------------------•--•-.........._................................................................................... Description of Soil---O.,`36.. 4_:LAO13/vi...... ------------------------------- U ........... .......... ....... --------------------------------------------------------------- W a i yy" C� sa��� z�G/. Y------------------------------------- x P U Nature of Repairs or Alterations—Answer when applicable................................................................................................ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TTT1E 5 of the State Sanitary Code—The undersigned fur r grees not to place the system in operation until a Certificate of Compliance has been iss by the -d of r i ned_. ..... Date Application Approved By.......... . ..Q: �"i—� Z- .z ----- •-• . . Date Application Disapproved for the following reasons--------------------------•-••-•--------------------------------------------•-------------------------------•--- ----------------------------••-•-----•......---------•-----------------•--....._.......................-----•-•------------------•----------•---------•-------------------- ••--•-----•---------------- Date PermitNo......................................................... Issued......._....------------•-•--...................------ Date r-� y THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 7 0.( ,� t7 Applira#ion for Bisposal Works Tomitrurtion runtit Application is hereby made for a Permit to Construct ( a() or Repair ( ) an Individual Sewage Disposal System at: _ .Location-Address or Lot No. .............................................. ......-•------............---------•------•----------.....-------•--------•-...................... :' __ Owner - Address 4-j ............................................. ..................................... � Installer Address UType ng Size Lot---..... 4��''�-----Sq. feet Dwelling—No. of Bedrooms.........3...............................Expansion Attic ( } Garbage Grinder ( ) i 44 Other—Type of Building ............. No. of persons............................ Showers . � YP g --------•------ -------------•-----P--- ( ) — Cafeteria ( ) d Other fixtures = W Design Flow.................5_�S�................... person per day. Total daily flow------- '`?r ----__-----_-----__--_-•gallons. WSeptic Tank—Liquid capacity.l(?;J.�!.gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No______ ____________ Diameter......ZO........ Depth below inlet.................... Total leaching area------------------sq. ft. Z Other Distribution box ( ) Dosing tank ( ) a Percolation Test Results Performed by..!�l'�':."...�r !' ._. jG R'. ._�.v............... Date...... ���' i-• ------_.•-- Test Pit No. 1........x...___minutes per inch Depth of Test Pit.....�`?' _ Depth to ground water.._r' ._._!`f . 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ----------------------------•------------•-----------•---•--.....---.....------......._..------••---............................_......-- -------------- O Description of Soil..--Q..'.7s'Z. ;�S �L. _ _s2. /�i.----Cry _ c3G.c/ - •---- ��. _=.�?t.---------------..... -......•••.. U .C�..__-.__l_7�1 C ---- � �r��� f�, cc� i,2iri°•v� i� !I`j W ..........12.0.,-'-----j `f.......... -r? r7 �f° � = ` '� UNature 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'.ITT- 5 of the State Sanitary Code— The undersigned fxf�lr tf grees of to place the system in operation until a Certificate of Compliance has°been jesued,by t4e,1SQ�rd of��} �y� Signed' _." `s Application Approved B �- _�{ :`4-`............................- �''i i l ` h`` "` ................... .........--............................. Date Application Disapproved for the following reasons--------------------------------"---------...------------------------------------------------------------------- .............••-----.................•••••-•-••--•--••--••-•------•••••••-•---•-•••-•-•---...•••--........-•••-••-----•-••-•-•-•-••--•-----•--••••-•••--•••----••-------•-•-•---•-•----•.....--•-•-•-•--- Date 'Permit No......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH s ..........................................OF _............................................................... Tnr#ifirttt of TontpliFanrr THIS I TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by ? -------------------------------------------------------------------------------------------------•--••-......--....----•--••-.... Installer has been installed in accordance with the provisions of TITLE 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 FU CTION SATISFACTORY. DATE �• •� --•-••-•--••----------------•----.........----..Jay Inspector .... -.6 .... ................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH rr:.... OF FEE........................ Disposal Works TwOns#rudion runtit Permission is hereby granted..,___. ._.___......._._.................................. to Construct (A\) or Repair an Individual Sewage Disposal System .at No..........i,-., ;f • - ---------------------------------------------------- .............. Street ^. as shown on the application for Disposal Works Construction Permit No._ �`�`�� Dated Z "=:==:� _ f .......................................................................................................•- Board of Health DATE....= 1 FORM 1258 HOB S 8i WARREN, INC,.-PUBLISHERS. ._ , L_og Number: Bottle # D347 Date: 2/21/85 8A`��s� BARNSTABLE COUNTY HEALTH AND ENVIRONMENTAL DEPARTMENT -k SUPERIOR COURT HOUSE a O HARNSTAE3LE, MASSACHUSEiTS 02830 to �rA56 DRINKING WATER LABORATORY ANALYSIS PHONE: 362-2511 EXT. 331 Client: Lou Gentili Collector: Edward P. Meehan Mailing Address:' _ M.G. Development " Affiliation: Meehan Well Drilling__ 91 Turnpike Rd. Time & Date of Westboro, MA 01581 Collection: 2/19/.85, 9:.15. 't, . Telephone: 778-4889 Type of Supply: well water m Sample Location: Lot 8 Coachmans La. 'Well Depth: -128' W. Barnstable Date of Analysis: -2/19/85 PARAMETER SAMPLE RESULT RECOMMENDED LIMITS Total Coliform Bacteria/100 ml 0 0 H 5.8 Conductivity (micromhos/cm) 5000 Iron ( m) 10:3 Nitrate-Nitrogen ( m) en nA 10,0 Sodium ( m) 20.0 I . xx Water sample meets the recommended limits for drinking of all above tested parameters. II . Based only on results of the parameters tested for this sample, the water is suitable- for drinking but 'may present the problems checked below:. A.._..•_�' , Water sample has .higher `than average levels of Nitrate: • Future monitoring i.s recommended (273 times per year) to establish any upward arends. B. The low. pH of the water may shorten the useful life of the house's plumbing. C. Water, may present aesthetic problems (taste, odor, staining) due to D. Water sample has high levels' of sodium. Persons on low sodium diets should consult their doctor. III. Due to one or more of the reasons checked below, this water sample is unfit for human consumption: A. High Bacteria B. High Nitrates REMARKS: CC: Barnstable Board of Health )(1-116- CC: Meehan Well Drilling 117/85 Laborato Director ASSESSORS MAP NO: -- `=-- -- f —-- No. � PARCEL NO: BOARD -- BOARD TOWN OF BARNSTABLE ZippYication-*rWell Cootruction Permit Aglication is hereby made for a permit to Construct (X), Alter ( ), or'Repair ( n individual Well at: � Its i =I T 17o- = - -= O Location — Address Assessors Map and Parcel 07er Address Installer,— Driller A dress Type of Building Dwelling-----------___-------____ L Other - Type of Building--- -- ----- No. of Persons--- ---- Type N of Well-l�l-__Gi`� -- ----_—___.___------ �6 - - - - - Capacity---------------------__ ___.---- Purpose of Well-- -- ------- —-A-- Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation — The undersigned further agrees not to place the well in operation u ' Certificat of Compliance has been issued by the Board of Health. OF Signed g date Application Approved By-- -— a t -�-L - A6 -----___-- Application Disapproved for the following reasons: ---- -— —------- ——_—__ --- --—— date Permit No. ---- ! _ ------— Issued----- — --- - -date BOARD OF HEALTH TOWN OF BARNSTABLE Certificate ®f Compliance THIS IS TO CERTIFY, That the Individual Well Constructed ( ), Altered ( ), or Repaired, by-- - — r - — ----�.`ram--------------- --------------------------------------------_-_-------------------------------- Installer l - ---- ----- -- 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. --( -'1�-- -Dated-------------------- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE —-------- Inspector ----- ---=----- _ A! Ic/ Fee-- - BOARD OF H'EA'LTH TOWN OF BARNSTABLE 0[ppritation-*rVerr Conf�tructiollPermit Application is hereby made for a permit to Construct (X), Alter ( ), or Repair ( )an individual Well at- --- _ �___C�✓/_ ----_ 0311 Location — Address Assessors Map and Parcel -------------------------------------------------- _!'des► --L`✓ O�w/�'er Address c3 --/e ----------- Installer — Driller Add ress— Type of Building Dwelling----------------------------------------------------------------- Other - Type of Buildin No. of Persons-- ---------- ---` ------------ ---------- YP g------------------------ Type of Well YP o,.> ---- - - ----------------------- -- Capacity—_--------------------------- Purpose of Well—aZ�gtAZ _ ----------------------- — Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation — The undersigned further agrees not to place the well in operation until-•a Certificate of Compliance has been issued by the Board of Health. •--j Signed . -��� -- �--------------------------- �d � /,� ----------- / date Application Approved BY- - C7 V - —'=---- date-= -- Application Disapproved for the following reasons:------------------------------------------------1---------- -- -- - -- ------------------------------------------------ date f PermitNo.------------'t�= � _ - - ----------------------- Issued------------------------------------------------------------------------—- date BOARD OF HEALTH .TOWN OF BARNSTABLE Certificate Of Compliance THIS IS TO CERTIFY, That the Individual Well Constructed ( ), Altered ( ), or Repairedf(x_)" bY— - - — - —-— ,1 (��/��� 11 Installer at_______________---__ ____ __a_a has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation as described in the application for Well Construction Permit No. Dated---------------- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE--------------------------------------------------------------------------------------- Inspector---------------------------------------------------------------------------------- BOARD OF HEALTH TOWN OF. BARNSTABLE Vern Con5tructionPermit No. 4r,e.9/_--' I nn Fee-- -�----- Permission is hereby granted----------- ---- f-r+'Q- --------------------------- to Construct ( ), Alter ( ), or Repair)-an Individual Well at: No. -- 1f— -- r ,•� ��� �== ^---------1.< 1m�J1' - - e -- - - - - - --- Street as shown on the application for a Well Construction Permit No.----------------------- ------ Dated------------------------------------------------------------------------ - ------------------------------------ :--i--- --------------------------=------------- �y Board of Health DATE - - --��-=---7%--- --------- - -- 1- t t ., ale .. ._ .. \ .. �F :. s ... -... _. '. r .. gyp. .. ,. v, _ .... ... .. b ,. "P ^a .. ...., a ri. 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Ci`r AIL--) 1T1q T1� >. - :. �rT�'ircrt do, � , -. � , „�, , ' � ,,., ,��c'C 7"r�iV .h'i4�� .fPIN` /r 'I-�.,_ . � 5 �•'S/E •-j' �:_. _ - ,.:. *2. ,,,,__.. .. ,-_ .� uy::t�Y'_„ �', ��- _ > >�.� t-C/i�..Lr!✓,�i���T/C,//��. r «J ORAO rra 7 'T « :n ..'i. ,I f -.., C./"r „�u'` _ ,. f ,!A,....:r ✓ L,r`"7 .:K./`d S.. 1^ N•+ +_ > J' J f"-• A�..W ,, x • - ;L Try, ;. 9 y ;.. 1 ( L, a j J ~ 4 A.., b 3 L-+ Y Y-f:,..+•,�i. l� CJ C„ _�A' f �v IN F j ,.w„ . ..:#.' i'°c;^:' ,'.':. .-'_ -` ,.:,,:.- ..: , t' )�, Y�lI�Y1A�.,>Mp Ylwaw• n a. vtVRAC + c - rc AV, ::�-, :.,.y :. � .. -•-i. P :. ...,. f/����,J}� .. .. _. ) ,... !�-. : /J l_+F-: I� •�/J �'! y {�+•'^���r ,Js-.,.. y' // , >t, , ,r I TOP FNDN. AT EL, 156.26' SYSTEM PROFILE TEST HOLE LOGS a ACCESS COVER TO WITHIN 6" OF FIN. GRADE (NOT To SCALE) / ACCESS COVER (WATERTIGHT) TO D.A. OJALA, SE ) ENGINEER: MINIMUM .75' OF COVER OVER PRECAST /� WITHIN 6" OF FIN. GRADE 2% SLOPE REQUIRED OVER SYSTEM 155.0' WITNESS: DAVE STANTON EL 154.0' RUN PIPE LEVEL 2" DOUBLE WASHED PEASTONE °qwq� DATE: 12/07 f 01 FOR FIRST 2' 3' MAX. PERC. RATE < 2 MIN/INCH EXISTING ]DOa o GALLON --RE SEPTIC 152.5't 152.0 CLASS i SOILS P# TANK (H- 1O } BGAS AFFLE 151.33' 0 p p p , 151.50' 0 151.17' 4 C7 � 0 C.] C7 Cl [� C� CJ >' 0 SIDES LOCUS 2 a �6" CRUSHED STONE OR MECWANICAL o 0 2.5 AT ENDS 11� ELEV. I s 2 0 0 Q [� L�7 C] C7 L CI d 149.17' 0" 155.0' COMPACTION. (15.221 [2]) o `� � o DEPTH OF FLOW = 4 ( 4 % SLOPE) ( 1 % SLOPE) 3/4" TO 1 1/2" DOUBLE WASHED STONE A TEE SIZES: LS INLET DEPTH 10 10" 7" 10YR 4/1 OUTLET DEPTH 14" g LOCATION MAP NTS FOUNDATION- EXIST SEPTIC TANK 23' D' BOX 180 LEAC-iING i L$ 8 FACILITY � ASSESSORS MAP 151 PARCEL 29 6.17' 2.5Y 6/6 _._..... 38 1 1 3' C WITH SILTY POCKETS . 14:_`� �l i 2.Y 6/4 I TOWN OF BARNSTA3LE VARIANCE ; LOT 7 REQUIRED: PROPOSED LEACHING FACILITY TO BE 11'5' TO EXISTING WELL (35' VARIANCE) EXISTING I WELL 144,. 143.0' 151.61 LOT 8 NO WATER ENCOUNTERED 44,087 SFf NOTES: 50' 62� _zo 2�08. A SEPTIC DESIGN: NOT ALLOWED (GARBAGE DISPOSER !S_ _ _ ) 1 , DATUM IS -APPROXIMATED FROM QUAD MAP , 7.4 `-��n Lt1 �^�A '� c>;'' �j - ~'- _vNU 2. MUNICIPAL WATER IS NU I AVAILABLE -_:t�.J I'JIY I LV Y1 ,-,•...� '7E:J I'C�VI1:i�i 156.27 I USE A 330 GPD DESIGN FLOW 5.32 156 BENCHMARK 330 3. MINIMUM PIPE PITCH TO BE 1/8' PER FOOT, CONCRETE BOUND SEPTIC TANK. GPD ( 2 ) = 660 4, DESIGN LOADING FOR ALL PRECAST UNITS TO BE. AASHO H- 10 .48 ELEV = 142,5' - 5. PIPE JOINTS TO BE MADE WATERTIGHT, 1000 ASSUMED USE A _ GA,'LON SEPTIC TANK (RE--USE EXIST) 5, CONSTRUCTION DETAILS TO BE IN ACCORDANCE WITH MASS. ti� F LEACHING: ENVIRONMENTAL CODE TITLE V. � 1 142, o T I Y// - 135 5'19 ��, ��' � % SIDES: . 2(39 + 6.83)`.-2 (.74) - 7. THIS PLAN IS FOR PROPOSED SEPTIC SYSTEM ONLY AND IS NOT TO BE USED FOR ANY OTHER PURPOSE. I SHOWER 5 39 x 6.8��(.74 - 197 „ P E I rk �� // BOTTOM: ) 8. PIPE FOR SEPTIC SYSTEM TO SCH, 40-4 PVC. / GASMET 3 DIVE UTILITY 9. COMPONENTS NOT TO BE BACKFILLED OR CONCEALED WITHOUT METER 15s 151 7 - �a TOTAL: 448 S.F. 332_ GPD 59. _ G o p POLE INSPECTION BY BOARD OF HEALTH AND PERMISSION OBTAINED / EXISTING I S uN AL G �-- // USE (4Z 500 GAL. LEACHING CHAMBERS WITH 1' STONE FROM BOARD OF HEALTH. OlVG DWELLING 156.2� 4. ...` F 1.24 RI _ RJ .-• r - r-. TF - 156.26 - 152. E T. IL P 75+ s. 62 ^4 2.14 140.00 AT SIDES AND 2.5 AT ENDS 10. PUMP & REMOVE FAILED LEACH PIT. EXISTIN 4' � �/ WEAL 55.21 / 55.7 1�55.74 �pV 02 3 142. `J FN 141.42 - 1&3.94 '// - 5,79 V REPAIR �o.74 2.83 a LEGEND TITLE 5 SITE PLAN 32 43.09 r- 157 100.0 PROPOSED SPOT ELEVATION OF EXISTING $ i PROP,(APPROX. 1 2T) SET AT 5'MIL LINER 697 14 2 COACHMAN LANE 1 - f WFLL . 15 �o �/ OFF EDGE OF LEACHING 100Xa EXISTING SPOT ELEVATION +157.22 + ,B .b' / - FACILITY AS SHOWN, 70P A7 . I 60 EL. 1 52.0, BOTTOM AT EL. I N THE TOWN OF: ^ / 148.0' 100 PROPOSED CONTOUR r 16� � % �`� ( WEST) BARN STABLE SO 162 � B ' Q� 100 EXISTING CONTOUR PREPARED FOR: DON ALD ZI CK �.41 30 0 30 60 90 Feet t 4159.0 4 BOARD OF HEALTH o� 0o MA SCALE: 1„ = 30' DATE: DECEMBER 12, 2001 5 .91 ,� APPROVED DATE +150.26362-4541 150.72 fox off 08-62-9880 I 1 f�• LOT 9 O �y fAss. 0c�1n down cape ell in e el"rin inc.C. q�� ARNE H. c ��� ABNE " Jd OJALA F, v CIVIL o .A 5.4 LA No.L6JdQ Ci ' CIVIL ENGINEER'S_ No,9o7 2 LAND SURVEYORS _ POLE I- y/o '5402 939,main st. yarmouth, Ma U2�'�5 - -- _ _- ..�._- 01 -32 Jc ARNE, H. OJALA, P.E., P.L.S. DATE I