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HomeMy WebLinkAbout0236 COACHMAN LANE #A - Health 236 Coachman Lan e. 151-033 Marstons Mills '1'aWia 4FIRARNSTABLE LOCA'IN �`` '` /�'I if ti v�' SEWAGE# 7 .1 `V3IhAGE �. VA—"ASSESSt}M14#AF cSc ,C)T II�STP, LER'§.NAPM&F491J N(? SBPTLC TANK'CfIFAC:�'t'Y �� z ' I L,EACfIIlIG FAt;II.�'t'K ( � Ito o BEDROor s � DER-0 :owl I�ERMITDATE. CONIPLANC Sepatstzon IS CC Between Ebc Feee Max�►um Ad�ustes]C�oundwater Tak�le to the$otlom of I.eachin$F�cii�ty kll vri,' ' Fac ltrl E �Y �Tls exist` pmate'�4►atatupply Feet- ottatts ar un�t�ua 240 feet of lea�ir�g f�;Y) Edge v£V�letland and°I�eacluz►g Eap'lty(IfY wetlands ex�sf Feef within 3t30€eet:"€'.eaching facility f'ariusbed bY:_ ✓' � G g 77'8�' Commonwealth of Massachusetts r� f � Title 5 Official Inspection Form ! m Subsurface Sewage Disposal System Form Not for Voluntary Assessments } 7P f U kt 236 Coachman Ln Property Address Len Rehard Owner Owner's Namek+ information is Barnstable M M MA 02668 10-11-18 r+ required for every page.e. City/Town State Zip Code Date of Inspection ; Ph- 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. A. Inspector Information 33+q Shawn Mcelroy Name of Inspector Upper Cape Septic Services Company Name P.O. Box 73 Company Address E. Falmouth MA 02536 City/Town State Zip Code 1-508-495-0905 S13971 Telephone Number License Number B. Certification I certifythat) am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 pp Y p p (310 CMR 15.000);1 have personally inspected the sewage disposal system at theproperty address listed above;the information reported below is true, accurate and complete as of the time of my inspection; and the inspection 'was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the system: 1.' ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the.Local Approving Authority 4. ❑ Fails 10-11-18 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system 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 form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: 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. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form >1 : i-I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 236 Coachman Ln Property Address Len Rehard Owner Owner's Name information is required for every W. Barnstable MA 02668 10-11-18 page. City/Town '' State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) 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: .System is in good working order with no sign of failure. 2) 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 folio_ wing 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): r t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Fora I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 236 Coachman Ln Property Address Len Rehard Owner Owner's Name information is required for every W. Barnstable MA 02668 10-11-18 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ 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 El ❑ ND-(Explain below): ❑ obstruction is removed - ❑ Y El ❑ ND (Explain below): El 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): 3) 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. a. 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: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form ^inl. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 236 Coachman Ln Property Address Len Rehard Owner Owner's Name information is required for every W. Barnstable MA 02668 10-11-18 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ 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 b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: []The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑The system has a septic tank,and SAS and the SAS is within a Zone 1 of a public water supply. ❑The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. c. .Other: ,, 4) 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 t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts �w Title 5 Official Inspection Form C�i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 236 Coachman Ln Property Address Len Rehard Owner Owner's Name information is required for every W. Barnstable MA 02668 10-11-18 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) I I 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® 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 ❑ ® 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 water supply 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 2000 gpd- 10,000 god. 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. 5) 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 CA. 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 t5insp.doc•rev.7/26/2018. Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 18 Commonwealth of Massachusetts •1� 3 Title 5 Official Inspection Form w., i 'I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �. _ 236 Coachman Ln Property Address Len Rehard Owner Owner's Name information is required for every W. Barnstable MA 02668 10-11-18 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes"to any question in Section C.5 the system is considered a significant threat or answered es"to y any question in Section C.4 above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. ' You must indicate "yes" or"no"for each of the following for all inspections: Yes No ❑' ® Pumping,information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the systemIcomponents 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) ® ElWas 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, de th of slud a and depth of scum? P , q P g P ® • ❑ Wasthe 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. [E ' ' ❑ 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)] t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18 Commonwealth of Massachusetts fY Title 5 Official Inspection Form l ..i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments - 236 Coachman Ln T i Property Address Len Rehard Owner Owner's Name information is required for every W. Barnstable MA 02668 10-11-18 page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flowbased on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 Description: Number cf current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ® Yes ❑ No If yes, discharges to: Outside Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No informatioi in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage Well water 9 ( Y 9 (gPd))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: 10-2018 Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 c Commonwealth of Massachusetts r,"P Title 5 Official Inspection Form C4 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 'q+c' ar 236 Coachman Ln Property Address Len Rehard Owner Owner's Name information is required for every W. Barnstable MA 02668 10-11-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. 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: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts t� f Title 5 Official Inspection Form 1,0 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 236 Coachman Ln Property Address Len Rehard Owner Owner's Name information is W required for every Barnstable MA 02668 10-11-18 e. City/Town State Zip Code Date of Inspection page. p D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ . Overflow cesspool ❑ Priv y ❑ 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): Approximate age of all components, date installed (if known) and source of information: 1980's with leach pit added in 1996 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 18"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.): Good condition. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form C�i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 236 Coachman Ln Property Address Len Rehard Owner Owner's Name information is required for every W Barnstable MA 02668 10-11-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: t 12" feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gal Sludge depth: 12" Distance from top of sludge to bottom of outlet tee or baffle 20" Scum thickness low 6" Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 15" How were dimensions determined? Tape 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 in good condition with baffles installed and no sign of leakage. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 Commonwealth of Massachusetts a Title 5 Official Inspection Form h.� IwJ o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 236 Coachman Ln Property Address Len Rehard Owner Owner's Name information is required for every W. Barnstable MA 02668 10-11-18 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. 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 t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 � ,,V Commonwealth of Massachusetts Title 5 Official Inspection Form w_ Subsurface Sewage Disposal System Form -Not for,Voluntary Assessments 236 Coachman Ln Property Address Len Rehard Owner Owner's Name information is required for every W. Barnstable MA 02668 10-11-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank (cont.) 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 9. Distribution Box(if present must be opened)(locate.ori 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.): Good condition with water at working level and no sign of back-up from pits. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 Commonwealth of Massachusetts r fw Title 5 Official Inspection Form hi Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �._✓„•,> 236 Coachman Ln Property Address Len Rehard Owner Owner's Name information is required for every W. Barnstable MA 02668 10-11-18 Cit /Town State Zip Code Date of Inspection page. Y P P D. System Information (cont.) 10. 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. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 1-1000 gal 1-600 gal ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: overflow cesspool number:El overflow m er. ❑ innovative/alternative system Type/name of technology: t5insp.doc-rev.7/28f2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form ! cali. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 236 Coachman Ln r . Property Address Len Rehard Owner Owner's Name information is required for every W. Barnstable MA 02668 10-11-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leach pits in good working order with pit 4 holding 36"of water and stain line at outlet invert. Pit 5 was empty at inspection with no sign of back-up. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration - Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No - Comments (note condition of soul, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18 r Commonwealth of Massachusetts a Title 5 Official Inspection Form A Subsurface Sewage Disposal System Form Not for Voluntary Assessments 9 p Y rY . 236 Coachman Ln Property Address Len Rehard Owner Owner's Name information is required for every W. Barnstable MA 02668 10-11-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. 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.): Lt5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form t''' i�i Subsurface Sewage Disposal-System Form Not for Voluntary Assessments Y, 236 Coachman Ln Property Address Len Rehard Owner Owner's Name information is required for every W. Barnstable MA 02668 10-11-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. 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 f of 4 W �l.�AFlA OI�fAl�ll��®�I t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 c Commonwealth of Massachusetts , r� f- Title 5 Official Inspection Form ht Subsurface,Sewage Disposal System Form -Not for Voluntary Assessments fk; fir-Jj' 236 Coachman Ln Property Address Len Rehard Owner Owner's Name information is required for every W. Barnstable MA 02668 10-11-18 page. City[Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 20 feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: ® Checked with local excavators, installers- (attach documentation) I ® Accessed USGS database- explain: You must describe how you established the high ground water elevation: USGS and town maps show groundwater at greater than 20'. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form i�t. Subsurface Sewage Disposal System Form Not for Voluntary Assessments. Y rY •:>�/ . 236 Coachman Ln • Property Address Len Rehard Owner Owner's Name information is required for every W. Barnstable MA 02668 10=11-18 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist) completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth p p h to high groundwater included t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 C �£ \� \AJ DID i - `r � /Zx, ----------- s.i f.p r'�11 C'('• i V 1 �.i COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS m � DEPARTMENT bF ENVIRONMENTAL PRO"T w $ RECEIVED ' d a Luu4 L'I(,,, TABLEMAY 0 4 2004TH DEPT. TOWN OF BARNSTABLE HEALTH DEPT. TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM MPV 5 1 PART A ,RCEL `Z 3 CERTIFICATION Property Address: 236 COACHMAN LANE WEST BARNSTABLE,MA 02668 Owner's Name: LAURA EMMONS c� Owner's Address: PO BOX 604 WEST BARNSTABLE,MA 02668 Date of Inspection:3131104 Name of Inspector: (please print) JOHN GRACI,INC. Company Name: SEPTIC INSPECTIONS Mailing Address: P.O.BOX 2119 TEATICKET,MA.02536 Telephone Number: 508-564-6813 FAX 508-564-7270 CERTIFICATION-STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: X Passes _ Conditiona sses _ Needs Fu r valuation by the Local Approving Authority Fails .' Inspector's Signature: Date: 3/31/04 The system inspector shall submit a opy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspecti . If the system is_a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner sha. submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments SYSTEM PASSED TITLE V INSPECTION. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This P Y P inspection does not address how the system will perform in the future under the same or different conditions of use. Titles S IncnPrtinn Fnrm 6/1'V)00 I I r Pad:.2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 236 COACHMAN LANE WEST BARNSTABLE,MA 02668 Owner: LAURA EMMONS Date of Inspection: 3/31/04 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: SYSTEM PASSED TITLE V INSPECTION.RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. B. System Conditionally Passes: _ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired.The system, upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND) in the for the following statements. If"not determined"please explain. n/a The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: n/a n/a Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): _ broken pipe(s)are replaced _ obstruction is removed _ distribution box is leveled or replaced ND explain: n/a n/a 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: n/a Page 3 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 236 COACHMAN LANE WEST BARNSTABLE,MA 02668 Owner: LAURA EMMONS Date of Inspection: 3/31/04 C. Further Evaluation is Required by the Board of Health: _ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well".Method used to determine distance n/a "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: n/a Page 4 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 236 COACHMAN LANE WEST BARNSTABLE,MA 02668 Owner: LAURA EMMONS Date of Inspection: 3/31/04 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all-inspections: Yes No X Backupof sewage into facilityor stem component due to overloaded or clogged SAS or cesspool b Y P bb P X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped SYSTEM HAS NOT BEEN PUMPED IN TWO YEARS PER OWNER. X Any portion of the SAS,cesspool or privy is below high ground water elevation. X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _ X Any portion of a cesspool or privy is within a Zone I of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well. X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] NO (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply _ X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well 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. d Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 236 COACHMAN LANE WEST BARNSTABLE,MA 02668 Owner: LAURA EMMONS Date of Inspection: 3/31/04 Check if the following have been done.You must indicate "yes" or"no"as to each of the following: Yes No X _ Pumping information was provided by the owner,occupant,or Board of Health X Were any of the system components pumped out in the previous two weeks X _ Has the system received normal flows in the previous two week period`? X Have large volumes of water been introduced to the system recently or as part of this inspection? X _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) X _ Was the facility or dwelling inspected for signs of sewage back up? X _ Was the site inspected for signs of break out`? X _ Were all system components,excluding the SAS, located on site? X _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum ? X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems`? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: Yes no X _ Existing information.For example,a plan at the Board of Health. X _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)] S Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 236 COACHMAN LANE WEST BARNSTABLE,MA 02668 Owner: LAURA EMMONS Date of Inspection: 3/31/04 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 5 Number of bedrooms(actual): 5 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):* 550 Number of current residents: 2 Does residence have a garbage grinder(yes or no): NO Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required] Laundry system inspected(yes or no): NO Seasonal use:(yes or no): NO Water meter readings, if available(last 2 years usage(gpd)): n/a Sump pump(yes or no): NO Last date of occupancy: n/a COMMERCIAL/INDUSTRIAL Type of establishment: n/a Design flow(based on 310 CMR 15.203): n/agpd Basis of design flow(seats/persons/sqft,etc.): n/a Grease trap present(yes or no): NO Industrial waste holding tank present(yes or no): NO Non-sanitary waste discharged to the Title 5 system(yes or no): NO Water meter readings, if available: n/a Last date of occupancy/use: n./a OTHER(describe): n/a GENERAL INFORMATION Pumping Records Source of information: SYSTEM HAS NOT BEEN PUMPED IN TWO YEARS PER OWNER Was system pumped as part of the inspection(yes or no): YES If yes,volume pumped: 1500gallons--How was quantity pumped determined?HICKEY CESSPOOL Reason for pumping: MAINTENANCE TYPE OF SYSTEM X Septic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool _Privy _Shared system(yes or no)(if yes,attach previous inspection records, if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank Attach a copy of the DEP approval Other(describe): n/a Approximate age of all components,date installed(if known)and source of information: 1991 PER OWNER,NEW LEACH PIT 1996 pee Were sewage odors detected when arriving at the site(yes or no): NO Pzfge 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 236 COACHMAN LANE WEST BARNSTABLE,MA 02668 Owner: LAURA EMMONS Date of Inspection: 3/31/04 BUILDING SEWER(locate on site plan) Depth below grade: 18" Materials of construction:_cast iron _40 PVC_other(explain): n/a Distance from private water supply well or suction line: n/a Comments(on condition of joints,venting,evidence of leakage,etc.): WELL WATER- 130' AWAY SEPTIC TANK: X(locate on site plan) Depth below grade: 12" Material of construction: Xconcrete_metal_fiberglass_polyethylene other(explain)n/a If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate) Dimensions: 1500 GALLONS" Sludge depth: 4" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: 0" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: 18" 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.): SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. GREASE TRAP:_(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Scum thickness: n/a Distance from top of scum to top of outlet tee or baffle: n/a Distance from bottom of scum to bottom of outlet tee or baffle: n/a Date of last pumping: n/a Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): n/a 7 I Page 8 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 236 COACHMAN LANE WEST BARNSTABLE,MA 02668 Owner: LAURA EMMONS Date of Inspection: 3/31/04 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Capacity: n/a gallons Design Flow: n/a gallons/day Alarm present(yes or no): N/A Alarm level:N/A Alarm in working order(yes or no): NO Date of last pumping: n/a Comments(condition of alarm and float switches,etc.): n/a DISTRIBUTION BOX:X(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE 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 STRUCTURALLY SOUND. PUMP CHAMBER:_(locate on site plan) Pumps in working order(yes or no): NO Alarms in working order(yes or no):NO Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): n/a i I R . Page 9 of 11 OFFICIAL INSPECTION,FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 236 COACHMAN LANE WEST BARNSTABLE,MA 02668 Owner: LAURA EMMONS Date of Inspection: 3/31/04 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: n/a Type P;4— AND NEWER PIT 6' X 4' leaching pits, number: 2 "uia leaching chambers, number: n/a n/a leaching galleries, number: n/a n/a leaching trenches, number, length: n/a n/a leaching fields, number: n/a n/a overflow cesspool, number: n/a n/a innovative/alternative system Type/name of technology: n/a Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.): DID NOT EXPOSE OLDER LEACH PIT.BOTH PITS APPEAR TO BE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY. SYSTEM SHOWS NO SIGNS OF FAILURE. CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: n/a Depth—top of liquid to inlet invert: n/a Depth of solids layer: n/a Depth of scum la yer:ayer: n/a Dimensions of cesspool: n/a Materials of construction: n/a Indication of groundwater inflow(yes or no): NO Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a PRIVY: (locate on site plan) Materials of construction: n/a Dimensions: n/a Depth of solids: n/a Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a 4 . . Pa-eA0of11 i OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 236 COACHMAN LANE WEST BARNSTABLE,MA 02668 Owner: LAURA EMMONS Date of Inspection: 3/31/04 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 buildings weio I A � b G �i OIL C, �)Zq �n A ` P.age I of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 236 COACHMAN LANE WEST BARNSTABLE,MA 02668 Owner: LAURA EMMONS Date of Inspection: 3/31/04 SITE EXAM _Slope _Surface water _Check cellar _Shallow wells Estimated depth to ground water 12 feet Please indicate(check)all methods used to determine the high ground water elevation: NO Obtained from system design plans on record-If checked,date of design plan reviewed: n/a YES Observed site(abutting property/observation hole within 150 feet of SAS) NO Checked with local Board of Health-explain: n/a NO Checked with local excavators, installers-(attach documentation) NO Accessed USGS database-explain: n/a You must describe how you established the high ground water elevation: HAND AUGER- 12 FT. IA I No. 7 1 /J / ee /00 V f THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -TOWN OF BAR,NSTABLE MASSA H SETTS R i Zipplicatton for Migpoal *p$tem Con5trurtton Ermtt Application is hereby made for a Permit to Construct( )or Repair(X )an On-site Sewage Disposal System at: Location Address or Lot No. Owner's Name,Address and Tel.No. 236 COACHMAN. LANE LAURA EMMONS 420/2496 /W Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. ARCH CONST HYANNIS 775/1362 Type of Building: Dwelling No.of Bedrooms--? Garbage Grinder( ) Other Type of Building No. of Persons Showers( ),Cafeteria( ) Other Fixtures Design Flow 310 gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Description of Soil Nature of Repairs or Alterations(Answer when applicable) ADD 1 600 GALLON LEAC Date last inspected: 10/4/9 5 �erC� Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Cod and not to place the system in operation until a Certifi- cate of Compliance has been issued b is Board of_Health Signed ` Date 10/11/9 5 Application Approved by ' Application Disapproved for the fo lowing easons Permit No. 175 7 Date Issued T ^ l 7 7 No. /SE t DO k - 4 THE COMMONWEALTH OF MASSACHUSETTS - PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSA - rtcattor� for fg oar patent Congtructtott.. ,, M jF i Application is hereby made for a Permit to Construct(-=)or Repair(X")an On-site Sewage Disposal System at: :.` Location Address or LodfNo. G' Owner's Name,Address and Tel.No. 236 .COACHMAN:,kLANE LAURA EMMONS 420/2496 r `t tInstaller's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. l ARCH CONST HYANNIS- 775/1362, Type of Building: Dwelling I No.of Bedrooms!- l Garbage Grinder •- Other \ Type of Building 7 No. of Persons Showers( ) Cafeteria( ) ' Other Fixtures Design Flow;:', 310 gallons per day. Calculated daily flow gallons. Plan Date '" Number of sheets Revision Date Title �"� Description of Sod _ 1 Nature of Repairs or Alterations(Answer whenapplicable) ADD 1 600 GALLON LEACH PIT WITH AgRE FEET 'ST-ON1E, AS-`PER PLAN Date last inspected: 10/4/85. � !� Agreement: ` The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi ,., cate of Compliance has been issued by Ibis Board of Health. Signed �. C Date 10/11/95 Application Approved by / — T'. Application Disapproved for the fo lowing easons t Permit No. 7 57 7_ Date Issued ��- 7. THE COONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVtI�SION - BARNSTABLE.MASSACHUSETTS Certif fcate of Compliance - THIS IS TO CERTIFY,that the On-site Sewage Disposal System installed( -)or repaired/replaced( )on by ARCH CONST for LAURA EMMONS aT 236 COARHMA has een constructed in ccordance- with the provisions of Title 5 and the for Disposal System Construction Permit No ' dated !� Use of this system is conditioned on compliance with the provisions§et forth below: - No. 1 -` t I Fee e/ y THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS . Mtopoal *pztem Construction Vermit Permission is hereby granted to ARCH CONST to construct( )repair( )an On-site Sewage System located at 236 COACHMAN LANE WEST BARNSTABLE 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. All construction most be completed within two years of the date below. Date: /6 -11 Approved by r :' issessor's Office(1st floor) Map Lot t# Conservation Office(4th floor) , ate Issued L/Board of Health(3rd floor)(8:30-9:30/ :00-2:00) Fee cca ;/Engineering Dept.(3rd floor) House#1 la ng ept t floo choo d 'n. g.) � �, SUEZ ' efi ' v an ve b 1 n o 9 ®P '(gdyJp40 6`rM, ��y TOWN OF BARNSTABLE de Building Permit Application °� �. Project a ddress Village_ OwnerU,P � ULI�IpJyS' Address Sc¢6 Telephone Permit Request Total 1 Story Area(include 1 story garages&decks) square feet Total 2 Story Area(total of 1st&2nd stories) square feet Estimated Project Cost $ 7`;1P00 Zoning District /� Flood Plain Water Protection Lot Size Grandfathered ? Zoning Board of-Appeals Authorization Recorded Current Use e! Gl Proposed Use Construction Type i�®o Commercial Residential Dwelling Type: Single Family Two Family Multi-Family Age of Existing Structure T,�S Basement Type: Finished Historic House /f/iq Unfinished Old King's Highway Number of Baths / No.of Bedrooms Total Room Count(not including baths) First Floor Heat Type and Fuel �77&5 Central Air Fireplaces, Garage: Detached. Other Detached Structures: Pool Attached Barn None ]/ Sheds /ya Other Builder Information Name Telephone Number 7-7/S Address_ 6K17 4 License# Home Improvement Contractor# I Worker's Compensation# * &/OS7 -e NEW CONSTRUCTION OR ADDITIONS REQUIRE A SITE PLAN(AS BUILT)SHOWING EXISTING,AS WELL AS PROPOSED STRUCTURES ON THE LOT. ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO 1i lU' SIGNATURE DATE . BUILDING PERMIT DENIED F R THE FOLL ING REASON(S) AsBuilt Page 1 of 1 , J TOWN OF BARNSTABLE LOCATION a� Co At/�s►r .✓ L.q�E SEWAGE# 7 S 7 VILLAGE — y�� ESSOR'S MAP&LOT/-�/- % INSTALLER'S NAME&PHONE NO. Ate-H 6"'sr 17 ,3�' ;�L SEPTIC TANK CAPACITY LEACHING FACILrrY:.(type) /�!t E c..$s r P/ / (size) NO.OF BEDROOMS r7� 1 BUILDER OR OWNER /Z A PERMITDATE: `l ✓ COMPLIANCE DATE: /4/..' l `/ II Separation Distance Between the: I, r Maximum Adjusted Groundwater Table and 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 http://issgl2/intranet/propdata/prebuilt.aspx?mappar=151033&seq=1 10/12/2012 TOWN OF BARNSTABLE LOCATION Co Ae/j^A no L AtiF SEWAGE# C --57 l 7 T 7 VILLAGE ^'TER ESSOR'S MAP &LOTIj• 3 INSTALLER'S NAME&PHONE NO. �=�� SEPTIC TANK CAPACITY LEACHING FACIL ITY: (type) ��s�- �i ! (size) �' � -NO.OF BEDROOMS 47, BUILDER OR OWNER PERMITDATE: ea ^l COMPLIANCE DATE: "41"y S " ation Distance Between the: ` aximum Adjusted Groundwater Table and Bottom of Leaching Facility . Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within t of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by • - 8 IJ 1 N i I ( Commonwealth of Massachusetts Executive Office of Environmental Affairs Department of o Environmental Protection �f{ �� William F.WeldGoarnor Trudy coxe 1� Ss W. .EOEA David B. Struhs Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM , PART A � CERTIFICATION Property Address: R3(o C 1®AcHmA LLrNW ��-�1�- IN) •Y' Address of Owner: Date of Inspection: to-k-9.* (If different) Name of Inspector: W:IV N1 Vo1Xn501\ SR• Company Name, Address and Telephone Number: RoNn5oesepi-ic yl CtAPr Eiji.,, Li4r, NYannty MA 61-1-06 Sob-`7?S-796G CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: _ Passes Conditionally Passes Needs Further Evaluation By the Local Approving Authority _ Fails Inspector's Signature: Date: (®'�(° �s.• The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (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 Department of Environmental Protection. The original should be sent to the ystem owner and copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: A] SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B] SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes inspection. Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not) The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 8/15/95) 1 One Winter Street a Boston,Massachusetts 02108 a FAX(617)556-1049 a Telephone(617)M-5500 >�Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 0136 CoAc_kmAtA Lar\L W'8PXn w - Oner t, Date of Inspection: 1()- -OJS Bj SYSTEM CONDITIONALLY PASSES (continued) _ Sewage backup or breakout or high static water I observed in the distribution box is due to broken or obstructed- pipe(s) or due to a broken, settled or uneve istribution box. The system will pass inspection if(with approval of the Board of Health): broken rpe(s) are replaced ob uction is removed rstribution box is levelled or replaced The system require'd,pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if MAfii approval of the Board of Health): brokenpipe(s) are replaced obstruction is removed Cl FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALT ETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEAL AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 5 feet of a surface water Cesspool or privy is with' 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLES HE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCJtONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRON,,IENT. _ Th system has a septic tank and soli absorption system and is within 100 feet to a surface water supNiy or tributary lu a _surface water supply. The system ha, a septic tank and soil absorption system and is within a Zone I of a public water supply well. _ The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. The systen) has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm• D] SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified belo The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage i o facility or system component due to an overloaded or clogged SAS or cesspool. Discharge ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspoo . (revised 8/15/95) 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: $Arn• Owner: L%VJ A E&V14no^S Date of Inspection: 1 o-y D]SYSTEM FAILS(continued): 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 in rt or available volume is less than 1/2 day flow. Required pumping more than 4 times in a last year NOT due to clogged or obstructed pipe(s). Number of times pumped Any portion of the Soil Absorp' n System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspo or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a sspool or privy is within a Zone I of a public well. Any porti 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: The following criteria apply to large syst s in addition to the criteria above: The design flo%�• of system is 10, gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment becaus ne or more of the following conditions exist: the system i ithin 400 feet of a surface drinking water supply the tem 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) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 8/15/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: COAChfgr% LA%-te. W°Barn- Owner: I-Aura Emmons Date of Inspection: i D'4"G 5- Check if the following have been done: Pumping information was requested of the owner, occupant, and Board of Health. None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. large volumes of water have not been introduced into the system recently or as part of this inspection. ✓ As built plans have been obtained and examined. Note if they are not available with N/A. The facility or dwelling was inspected for signs of sewage back-up. 1/The system does not receive non-sanitary or industrial waste flow The site was inspected for signs of breakout. ZAll rals system components, e1xC41oUd ig the Soil Absorption System, have been located on the site. VThe septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or /tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. y The size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. ZThe facility ov_ncr (and occupants, if different from owner) were provided with information on the proper maintenance of Sub- Surface Disposal System. (revised 8/15/95) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: o136 CoAC k MAA LAnt W° )ern. Owner: Lnv!'A Emmons. Date of Inspection: 1 $•9� SEPTIC TANK:v (locate on site plan) Depth below grade: Material of construction: t/concrete _metal _FRP—other(explain) Dimensions: 10 (o"" x S'8' Sludge depth: 0 Distance from top of sludge to bottom of outlet tee or baffle: C Scum thickness: Distance from top of sou"m to top of outlet tee or baffle:_ Distance from bottom of scum to bottom of outlet tee or baffle: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) Ri\k 0 F\A1 r,F wMer opt fl Tin, - Or etk v k GREASE TRAP:_ (locate on site plan) Depth below grade: Material of construction: _concr a _metal _FRP _other(explain) Dimensions: Scum thickness: Distance from top o/CIM to top of outlet tee or baffle: Distance from bottom ni sc'um to bottom of outlet tee or baffle: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) (revised 8/15/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: a3 6 COAtWmijN LWw, W,RArn. Owner: LAvt-p t rAIA 71IS Date of Inspection: I O.4_q5; FLOW CONDITIONS , RESIDENTIAL: Design flow: (10 gallons Number of bedrooms: 3 Number of current residents: I Garbage grinder (yes or no): K)Q Laundry connected to system (yes or no): Seasonal use (yes or no):_hM_ Water meter readings, if available: o� r wiNAe 6,�I Last date of occupancy: COMMERCIAUINDUSTRIAL: Type of establishment:_ Design flow:_gallons/day Grease trap present: (yes or n _ Industrial Waste Holding nk present: (yes or no)_ Non-sanitary waste disc arged to the Title 5 system: (yes or no)_. Water meter readings, if available: Last date of occupancy: +o-S-I OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING g CORDS and source of information:HomeOwaamr Rf tl(on ►11MAIA4re RfS*N^ LOWiAM epw4jdA 6'epye System pumped as part of inspection: (yes or no)_kg If yes, volume pumped. _ kallons Reason for pumping. TYPE O 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) Other(explain) APPROXIMATE AGE of all components, date installed (if known) and source of information: 77-12--91— Sewage odors detected when arriving at the site: (yes or no) (revised 8/15/95) 5 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: c1 3 b Cogc H ihAN i.An t Owner: tpwrq Emmt(v5 Date of Inspection: t®_4-cl 5 TIGHT OR HOLDING TANK: (locate on site plan) Depth below grade: Material of construction: _concrete m I _FRP—Other(explain) Dimensions: Capacity:_________gal I s Design flow: Ilons/day Alarm level: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX:_ (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if level and distributicn i, eq,-,a!, e,,idence of so!ids car ,yover, evidence of leakage into or out of box, etc.) D—Bus « like tyew to,idi4i^A IVm rArrvojer o^IevFa5c- PUMP CHAMBER:_ (locate on site plan) Pumps in working order:(yes r no) Comments: (note condition of p p chamber, condition of pumps and appurtenances, etc.) (revised 8/15/95) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: A36 C0aeNMA41 LAIV_ Lass DAM Owner: Llivrp, C mmoms Date of Inspection: I0-q—q.5* / SOIL ABSORPTION SYSTEM (SAS): c1 (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type' i ( 00 leaching pits, number: leaching chambers, number:_ leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.) L.tgeh ,pif was 011V fZ,4 Full rah -fjmg_ nc nsnectrorl like (!etas lina SA0,05 heuftf- tin Nfiec VAN full in Lo+Gll 41n a 49 srt5Qec+i6e% CESSPOOLS: _ (locate on site plan) Number and configuration:Z. Depth-top of liquid to i t invert: Depth of solids layer Depth of scum la r: Dimensions of esspool: Materials of construction: Indication of groundwater: inflow (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY:_ (locate on site plan) Materials of c struction: Dimensions: Depth of so' s: Comments: (note condition of soil; signs of hydraulic failure,, level of ponding, condition of vegetation, etc:) (revised 8/15/95) 8 i j . �e� SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) 3 Property Address: i Owner: Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' u _ D rs0a ® y� to 9 4 � • .Q1 LP b�Q�'`'�e� SAVO- DEPTH TO GROUNDWATER Depth to groundwater: 1 bAr feet method of determination or approximation: `05� 60lu PIAA 1:13$.1 - pme. $ (revised 8/15/95) 9 r J No.—�I THE COMMONWEALTH OF MASSACHUSE17S BOARD OF HEALTH ----....,��`� ..........OF....- ........ ..................................... ..._.................._ S Na/� Appl ration for Biquiial Works Tunutrurtion Vrrmit Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal System Location-Address or Lot No. Owner Address W Installer Address UType of Building Size 5.5Z..Sq. feet t �-. Dwelling—No. of Bedrooms.._.-.�.-•.....................•.......Expansion Attic 06) Garbage Grinder ( 4 Other—Type of Building _._...... Showers — Cafeteria c� YP g ---------------».-----..... No. of persons-------......---•-= ( ) ( ) Q' Other fixtures W Design Flow._»_.._.___._.__. , »......._..gallons per person per day. Total daily flow.............» 3U------__.._gallons. R: Septic Tank—Liquid'capacity/-,<OO.gallons Length-•.1 .Width_.., �� Diameter---_ ..... Depth-.Z-..'."' Disposal Trench—No.------------------ Width..._...............Total Length......_........_....Total leaching area-._• »---.--._.sq. ft. 3 Seepage Pit No..----.[............ Dim aeter----12�.......... Depth below inlet.... Total leaching ..__sq. ft. area.. ._ _ . z Other Distribution box (� Dosing tank WO) A -A Percolation Test Results Performed by-gy 1 Test Pit No. 'P3Y.Z4....minutes per inch Depth of Test Pit---1_Z--........ Depth to ground water..A-1'21�? ... -� Gi, Test Pit No. l» G Z.---m �minutes per inch Depth of Test Pit._�_ _..._._.. Depth to ground �7 i ".3.9Aj-•................... ...._..................... _•_»_..... D Description of Soil.» =°7'7 P .�q Q1.�--•-_------------------- ---'Zss-..--_7..?J'�---�---�35rr-----_---- --------------- v _................... 3--1_z�_._f ,�5.P .x'_ ___-----------Z=S"� �s� -S�a,v� � •--n t ----....-- - - -.. W -_-'"o �'!"' » » -...G '!3-- .517-'-'-----i�_-----`�Y..---�"c'� 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 TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Date .:....__» ApplicationApproved BY..........-............»....................»_».._ ...._........._......... --•---------------nau ------- ---- Application Disapproved for the following reasons:...................................................................... ._..._.........--.-----..»»---- » --------------—----—-------------------------------_-------__..........�-- ------.......—........_.................................._................... Dau —»---» PermitNo.............»_»......._- -- Issued_-_-»--»....._.......-.........._-................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF............ 7�7it-�3L e....................... Trrtif irab of (Eomplianrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) bY...-...................»..........................-............_..........._...............................».--».--------•----•--•-•----_...--------------._....-----.......--•--»--»- Installer at.............•--....---•--...------•--•......_..---•••--••--------------•-----••-•--...-------•••--------•........--•---.._.....-------•-•----•--...-•--•-•-•--•--•..........--••--••---------------- Iias 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 FUNCTION SATISFACTORY. - I TOWN OF BARNSTABLE -4 - LOCATION - UYr* /2 C�4 (�."kH (c��t SEWAGE # VILLAGE lJ Ixt/LNJ talCc, ASSESSOR'S MAP & LOT p�INSTALLER'S NAME & PHONE NO. .J , �Qv�Lcr )A U )-G771 'SEPTIC TANK:CAPACITY ► r vy U(l o, &LEACHING FACILITY:(type) o y . U (size) Qt IRN0. OF BEDROOMS 3 PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER tc, 6, DATE PERMIT-.ISSUED: _7A 1� DATE COMPLIANCE ISSUED: VARIANCE GRAINED: Yes No 3�,10 r , 6 , v� TOWN OF BARNSTABLE LOCATION Co Act .✓ L/s����F SEWAGE# L ! 7 7 11VILLAGE "-- , �1%K88ESSOR'S MAP &LOTA52, 4-V INSTALLER'S NAME&PHONE NO. Pi�'G� � sr / �� SEPTIC TANK CAPACITY LEACHING FACILITY: (type) f c�s �i i (size) s NO.OF BEDROOMS BUILDER OR OWNER PERMTTDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and 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 �, C? '; . 1 Z TOWN OF BARNSTABLE L Lt)CA ON SOT I'f cyacti'myH (cf,,-( SEWAGE # ��✓� VILLAGE i l 1 / .1 ASSESSOR'S MAP LOT Asz r4 6�INSTALLER'S NAME & PHONE NO. `'SEPTIC TANK CAPACITY ► S cw L—(lo,., BLEACHING FACILITY:(type) (.o 0 Cry . (size) f t O. OF BEDROOMS 3 PRIVATE WELL OR PUBLIC WATER ��/ BUILDER OR OWNER DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No •�',� l (' � �� r f , �. i ;3`e�c� r r �l�� ` I� L�f a TOWN OF BARNSTABLE LOCATION Z� (naCN UnAN /Ane SEWAGE # 9�r�S 6 VILLAGE , ! ASSESSOR'S MAP &LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY 15,00 LEACHING FACILrrY: (type) P (size) LP'6 0 0 NO.OF BEDROOMS 3 BUILDER OR OWNER ZAur.fl Cn1✓ttoAI C, PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and 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) l3® u 1TY meet Edge of Wedand and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnishedby a F � �* f 6, ' No... !✓ L .J � Fps... r� ._....._. ............... I /S-6 THE COMMONWEALTH OF MASSACHUSETTS • BOAR® OF HEALTH ......... ........-.OF...` =? 51L................. .............. ................................... Appliration for Diipusal Works Tonstrnrttun Frrutit Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal System at: GlGf/.lif � L �� [,JEST Location-Address � or No � ,...... . � . . . 471 . --- ,-.144.......•............... Owner Address I W Installer Address d Type of Building Size Lot... J feet V Dwelling—No. of Bedrooms__.... ................................Expansion Attic (CJO) Garbage Grinder + Other—T e of Building No. of persons............................ Showers — Cafeteria Q' Other fixtures ----------•---- ---•----------------•---------...._.... -- W Design Flow.................... . .............gallons per person per day. Total daily flow................ 3 ..............gallons. WSeptic Tank—Liquid capacity/.____gallons Length.__/ 'j.Width._. .' Diameter----- Depth..s' �r x Disposal Trench—No..::-'................ Width.................... Total Length.................... Total leaching area... ......sq. ft. Seepage Pit No--------t.............Diameter....12.......... Depth below inlet... 3__ ...... Total leaching area. 7 ..sq. ft. Z Other Distribution box Dosing tank (NO) a Percolation Test Results Performed by.11pP— ..: 4x�', LR9G 7 e.... ,.a Test Pit No. *P3VJ....minutes per inch Depth of Test Pit._.,f.Z.......... Depth to ground water._.. Test Pit No. Z.._G_Z_...minutes per inch Depth of Test Pit...l.�.......... Depth to ground water.. ? ..*AZ,0V.v 7>-139A?.....................................................0i.............................:........................................................ O Description of Soil.... 4 L �z'S 7 r? L W --------------------v--... !�.sJ��.- ,too cO+r.�-..------------..I..- '!�� �4��r� �1 c VNature of Repairs or Alterations—Answer when applicable............................... ._.: -�...........................__. Agreement: ��/9? Z e- �e f'l�D kb,, 1,4 i6 �5 G�A41 I;,3 The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITA LE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has n issued b the b and of health. „ .. o Signed... ---- .............�. ..r.. -- ..........................------ Date r'll l ate e7 Application Approved By.. 6..--••-•&V- -__- ...._ ..��=,�ehd��a EN � 4--�-- Application Disapproved for th o owi g easons:..... .............. ........ �`z tnhVi gTWj:ocfl,-- - LEA J '51 _CERTIFY NrEi RMTU1F y __N_................................................................................................ a MIAO 04 TIN,,- CcO 11IMS,TRiC Permit No.._.......f•�` 1��----------------- Issued--.-....-....-.... ....... ....................... na r c �1 _ 33 FEB.. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ........OF..... ?�. ............. ....... Appliration for Disposal Works Tontrnrtion ramit f rApplication is hereby made for a Permit to Construct (KI) or Repair ( ),an Individual Sewage Disposal System at: [G v-4-r- Z mac A�U� 7- S7- Icy f Location• -Addr ss or It No. I ... - ................•••••. Owner Address W -----------•--•-------------------- ---- Installer Address , Type of Building Size Lot____7 SSSZ Sq. feet T Dwelling—No. of Bedrooms............................................Expansion Attic VC) Garbage Grinder *)dj 04 Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) a 1 Other fixtures ............................ . W Design Flow.......................... 5___....gallons per person per day. Total daily flow.....�J_� ....._.._.............__gallons. WSeptic Tank—Liquid'capacity/�--?-gallons Length.f4._�4 Width..�� .:�. Diameter.___`--........ Depth-S/8 I.I.. x Disposal Trench—No..................... Width.... Total Total Length....3.S.i_._ Total leaching area....................sq. ft. Seepage Pit No.......I............ Diameter...... Depth below inlet.......:............ Total leaching area..-...-----_..__..sq. ft. Z Other Distribution box Dosing tank (Ak>) '-' Percolation Test Results Performed byjV?'P � ' Q?:_. �� �!! Y Date.../!...._ -- ,tea Test Pit No. P_3 z`Z....minutes per inch Depth of Test Pit....lL_!........ Depth to ground Test Pit No. ...minutes per inch Depth of Test Pit----/32....... Depth to ground water ?t_.! ��' ................................................................................ O Description of Soil_4-371 `��So��...... O-2.5 ''7a-i? *�&�5e,7 � x ----------------• -------•---------------------.----- ---- ------------- -- W --------•-••-----•----------------------------Via•---�' -'------= ---------------•G'-�... ST tn, i h SIL?Y f=/.c•�- �D... U Nature of Repairs or Alterations—Answer when applicable !� �`'P".`fGs ........... ..:.z........ - Agreement: 4`S [7 ice/� C Z `' , //.0 The undersigned agrees to install the aforedescribed Individual Sewage ll si po ystem in accordance with the provisions of TIT1Z 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has �e)en issued by the oard of health. Signed...!.`�i !1Ca� __ ('+ j. �=..�.. ..-- ---- ---.-.-�..... i - ----- n �^ A�ate Application Approved By-dk------ .... /'. _t_._. Ld!Y`..._-.. ?`-- C�'f..�_.... -----6t ":.. .....,/�CCGC�l.f y� � ate Application Disapproved for thego�g reasons:.. -) .....�--------------19---------------------------------------------------..----------------------- ..............•.......--•---•-------•--------------------._..................•-----....---.....--•--.........................------•--------•-------------•---------------------•-------•---------------- Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................O F.... ...................................... Trrtif iratr of Tomplianr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by----- ---•..............•••--......................-••- ---------......---••--•--• -- ---------------.------.--------------------- U'1 `� �� /__ In f , v� has been installed in accordance with the provisions of TI 5 gI The State Sanitary Code jas desc 'bed in the I-W application for Disposal Works Construction Permit No.......................................... dated_..�j:'..!._ ..es ..._.........._._. " THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. MUST SUPERVIl DATE......./ �. -... Inspecto .._wf ��" E. _----=--=- •. CTALLATION AND I�'�TIFY 10 .."I I i�i THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 7 Sr..........OF.... ��- -- ......................... �No.. ... ... FEE..................--•--- Dispoottl Worko Tontrurtion rrmit Permissionis hereby granted.............................................................................................................................................. to Construct ( ) or Repair ) an Individual Sewage Disposal S1yst atNo....---�r •.-_•� Z— = ..----..lr ";!a.............W....... . .. .................................................. Street as shown on the application for Disposal Works Constructio Permit No.._ �¢� Dated...___--:..--- ..�. ..... ...... ....... . Cx. '--- Board of Health DATE................................................................................ FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS 1 .q�!Tr!11*tt!!ITi�!!It!!t!!1t!r!i!r!tinprr nn...... ..rrn..nrnr .. . .n....nnn m r rr r nnnnm n r n n+r+Tm+r+rmr rr u n nn n ru nr rr+ t n tt r n r + r rrrr++ r .:.:.:..::..::s:: s::r::,:::I::sr,,:r:,r::::r,:::::r ..,!:,rs,!.,rrs,::.r:::,:.:s:::,::rr,:rir„t::s::,,i.... .,l..,r,,,trt,r:,i„!1st,rns,:r,tttsr,ttr:t:,,,s,:r:>>� c ENVIROTECH LABORATORIES =_ Mass. Cert.#:MA063 449 Route 130 Sandwich,MA 02563 (508) 888-6460 = z`= CLIENT: Gene Rufo LOCATION: _ Lot #12 Sterling Tern _ i% ADDRESS: _ W. Barnstable,MA COLLECTED BY: Ray Leary SAMPLE DATE: 4/19/91 TIME: 4:40 PM DATE RECEIVED: 4/19/91 SAMPLE ID:BC 802 JOB �: Existing Well WELL DEPTH: 395 Ft :: --- — ': RESULTS OF ANALYSIS: c- - t: E_ Parameter Units Recommended limit Result Coliform bacteria/100 ml (MF Method) 0 e pH pH units 6.0-8 5 z' Conductance umhos;cm 500 Sodium - mg;L -- 20.0 z 7.3 Nitrate-N mg/L 10.0 Iron mgjL 0.3 _ ` Manganese_ 9 mgi L 0.05 Hardness mg/L as CaCO 500 t= 3 e: Sulfate mg/L 250 -' Potassium mg/L 20 0 ; Alkalinity mg/L 200 _-- Chloride mg/L 250 3= c: Turbidity NTU 5.0 _ Color APC units 15.0 .3 Background bacteria _ COMMENT: E Volatile organic compounds ug/L see attached NONE DETECTED ' (EPA Method 601/602) =x �y '= YES No WATER IS SUITABLE FOR DRINKING PURPOSES FOR PARAMETERS TESTED. XXX ❑ DATE +i1111111I1i1111U1Ulllllllll1111IUllililUlilllWlllll111llllllll{illllllllllllllli{illi Will iiIII;lii lllil{iii,111111"I Ili ii III,iilillii1IlulimiltilliUilliilllillliiflUlliiliii Mill ii� t � , +�inrmrrr�rrr11'rttnrnnttsrnnr!n(ttl!nrmnntttlryntilnlntn((rttrtrttp„rT,rr„rnn... ..Tttr,r,Ott,n„f�.ltnnt.rtttnrt�„ttft,int�tf„,trtrrTnrrr,r,ntnrnrt,frtntntt nr tt nntn, to t ftn nnrrr h- ENVIROTECH LABORATORIES _ Mass. Cctt.#:MA063 `- 449 Route 130 Sandwich,MA 02563 (508) 888-6460 CLIENT: Gene Ruffo LOCATION: Lot 12 Sterling Tern ADDRESS: W. Barnstable, MA - r =_ COLLECTED BY: Ray Leary SAMPLE DATE:4-19-91 — TIME: 4:40pm DATE RECEIVED: 4-19-91 SAMPLE ID: ET 80A JOB Existing Well WELL DEPTH: —395' — _ RESULTS OF ANALYSIS: r:- Parameter Units Recommended limit Result Coliform bacteria/100 ml IMF Method) 0 0 �. pH pH units -- -- 6.0-8 5 7.81 Conductance umhos.-cm 500 328 - 'Y Sodium mg-L 20.0 32.0 Nitrate-N mg;'L 10.0 <0.03 c Iron mg/L 0.3 0.43 - Manganese mg/L 0.05 == Hardness mg/L as CaCO 500 �- 3 r Sulfate mg/L 250 =' Potassium mg/L 20.0 Alkalinity mg/L -- 200 �- x Chloride mg/L -- 250 IFE Turbidity NTU ' 5.0 F Color i APC units 15.0 -'s - Background bacteria '3 COMMENT: Sodium level is not a health hazard. Iron level is not a health hazard. E_ - k - YES No WATER IS SUITABLE FOR DRINKING PURPOSES FOR PARAMETERS TESTED. Y ° °= 6W& 14&�26— DATE '<�t Ill I111t111 ill I1 III 11t11III III hill IIiIIUllilllli111111hill►ll11 lilt 111111111I1,, ism isit!II!H III t lilt Hill!Ili Ill Will iill it,HII11.11 lilt 11itI imiiiltittllitlllitiIItIhiIt'il"III lilt ill ItI Ili illilllfillh Ill I lilt Illil Ill IIItitiil�` . 1 I GROUNDWATER ANALYTICAL EPA METHODS 601 and 602 Volatile Organics (GC/PID/ELCD) Field ID: 802 Lab ID: 1200-01 Project: Rufo/802 QC Batch: VGA-754 Client: Envirotech Sampled: 04-20-91 Cont/Prsv: 40ml VOA Vial/Cool Received: 04-22-91 Matrix: -Aqueous Analyzed: 04-24-91 PARAMETER CONCENTRATION REPORTING LIMIT (ug/L) (u9/L) Dichlorodifluoromethane BRL 5 Chloromethane BRL I Vinyl Chloride BRL 1 Bromomethane BRL 5 Chloroethane BRL I Trichlorofluoromethane BRL I 1,1-Dichloroethene BRL I Methylene Chloride BRL 1 trans-1,2-Dichloroethene BRL I Methyyl tertiary Butyl Ether * BRL 10 1,1-Dichloroethane . BRL cis-1,2-Dichloroethene * BRL I Chloroform BRL 1 1,1,1-Trichloroethane BRL I Carbon Tetrachloride I BRL I Benzene BRL BRL I 1,2-Dichloroethane BRL I Trichloroethene BRL 1 1,2-Dichloropropene BRL 1 Bromodichloromethane BRL 1 2-Chloroethylvinyl Ether BRL I trans-1,3-Dichloropropene BRL I Toluene BRL I cis-1,3-Dichloropropene 1,1,2-Trichloroethane BRL I Tetrachloroethene BRL 1 Dibromochloromethane BRL 1 Chlorobenzene BRL I Ethylbenzene BRL 1 m+p-Xylene * BRL 1 o-Xylene * BRL 1 Bromoform BRL BRL I 1,1,2,2-Tetrachloroethane BRL I 1,3-Dichlorobenzene BRL 1 1,4-Dichlorobenzene BRL I 1,2-Dichlorobenzene QC SURROGATE COMPOUND SPIKED MEASURED RECOVERY QC LIMITS Bromochloromethane 30 30 100 % 83 - 117 % Fluorobenzene 30 30 100 % 87 - 113 % BRL = Below Reporting Limit. * Non-target compound. "Trace" indicates probable presence below listed Reporting Limit. Method References: Method 601 - Purgeable Halocarbons and Method 602 - Purgeable Aromatics, 40 C.F.R. 136, Appendix A (1986). i Hof THE r�r TOWN OF BARNSTABLE.. 6�?�.�♦� OFFICE OF DAE PAN& L � BOARD OF HEALTH 70 A/l oe�261%. 367 MAIN STREET '£0 MI1 HYANNIS. MASS. 02601 a , ' r Sewage Permit # ~]— 44CD Applicant :i�er --�o1w5 Proposed Installer: The plan for the on-site sewage disposal system at Lod i'a CoOd&m" Ln1 has bean approved with the condition that the design engineer must be on-site and supervise installation as well as certify in writing that the system was installed in strict accordance to the. approved plan. Approved By. Date 1 ftN t TOWN OF BARNSTABLE. P f OFFICE OF i DADIlSIBLE ! BOARD OF HEALTH MIV l 361 MAIN STREET HYANNIS, MASS. 02601 _ Sewage Permit # I IqCD Applicant :tom_+-zr t�IMaS Proposed Installer: The plan for the on-site sewage disposal system at Lam`. Z Coac",) Ln w� l�l�rinsc, has been approved with the condition that the design engineer must be on-site and supervise installation as well as certify in writing that the system was installed in strict accordance to the approved plan. Approved By . Date LABORATORY ANALYSIS d e E A Stevens Water AnAlysis 38 Montvale Avenue a Stoneham, MA 02180 * Mass. (617) 438-6114 • Salem, N.H. (603) 893-3106 LABORATORY NUMBER: 167051 SAMPLE DATE: 5/14/07 SUBMITTED BY: WILMINGTON PUMP SUPPLY 639 Woburn Street Wilmington, MA 01887 SAMPLE SOURCE: New Artesian Well/collected from pump Peter Holmes, Barnstable, MA ANALYSIS : According to Standard Methods of Water and Wastewater Analysis, 15th Ed . i Total Coliform . . . . . . . . . 0 per 100 ml Chlorides . . . . . . . . . . . . 26 mg/L PH . . . . . . . . . . . . . . . 8.0 Hardness . . . . . . . . . . . . 82 mg/L Manganese . . . . . . . . . . . .. 0.16 mg/L Sodium . . . . . . . . . . . . . 37 mg/L Iron . . . . . . . . . . . . . 0.98 mg/L Nitrate . . . . . . . . . . . . .. less than 0.10 mg/L Nitrite . . . . . . . . . . . . . less than 0.10 mg/L COMMENT : The results of these analyses meet the required federal and state standards for drinking water. However, the iron, manganese and sodium concentrations exceed the recommended standards. Although iron and manganese are not harmful to your health, they can affect the taste, color and odor of your water. Iron, manganese and sodium are frequently found at elevated levels in new wells; however, it is likely that these con- centrations will decrease when the well is put into regular use. Che ist/Micro iologist i. .f Depergnent of Environmental mppagement/Utvisaon of water Mesourcee WATER -WELL COMPLETION REPORT 1 v. {� WELL LOCATION Address J�e'r1//l 0 City/Town W arnsf able G.S.Quadrangle Map Grid Location Owner - RiW Holmes Address go SIIV I4.+Sll yi a. 6(9 Wm Sfi; wr(utii l . WELL USE CONSOLIDATED WELL Domestic Public ❑ Industrial 0 Other Type of Water�earing Rock 0 l Water-bearing Zones t O�AY 1) From U1 To �Q5 Method Drilled 2) From To' Date Drilled —� DI$7 3) From To 4) From. TO CASING a Depth to Bedrock 37T Length 3 Diameter Type G UNCONSOLIDATED WELL STATIC WATER LEVEL Water-bearing Materials. Feet below land surface Sand: floe❑ medium❑ coarse 0 Date measured Gravel: fine.0 medium❑ coarse 0 Screen: GRAVEL PACK WELL Slog length.' from to Yes 0 No ® Split Screen for 2nd.screen) WATER QUALITY TESTS MADE Slot# length . from to Chemical 0 Biological 0 Depth To Bedrock PUMP TEST Drawdown feet after pumping days hours at GPM. How measured. - Recovery feet after hours. LOG of FORMATIONS COMMENTS:(On well or water) Materials From To i.7 D VJS l D &PA p lad ,— r y DR; E c Firm I er a mpont 'rm AddressCityRegistration No.L"', CL44— perator s ignature CUSTOMER COPY atl'lo es aonal t N I� E- J�'l�e} HA A3 t40Lf-- A/�r-*A Co v FiAJ,sN C.A!ADt TC.> • �._ .----F>rt1�S H C.k'A Z?� L.6 AG t�a�c.a'G, tA�-r�i TY V&P O,F G4.WA-)D,�}T/cam __ f- AGE '" 3, e 4 4 rTt A44r ,T Lr ,. ., s �/��f1Ate:E D G.eaauc. ...e••-, -"'....,«...-,-- ��$4 p r/c A.. �. v" 1---- uAc4 PiT /' T^ N.. . 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