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HomeMy WebLinkAbout0105 BERKSHIRE TRAIL - Health 105`Berkshire Trail W. Barnstable P A = 109 015010 - -- - C RECEIVED ECOJECH NOV 242004 Environmental TOWN OF BARNSTABLE www.eco-tech.us HEALTH DEPT. THIS FORM IS A FACSIMILE OF THE STANDARD SEPTIC INSPECTION FORM ISSUED BY THE MASSACHUSETTS DEPARTMENT OF ENVIRONMENTAL PROTECTION(revised 6/15/2000) TITLE 5 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 105 Berkshire Trail West Barnstable Owner's Name: George&Nora Brown AP a. Owner's Address: 105 Berkshire Trail West Barnstable,MA 02668 PARCEL Date of Inspection: November 16, 2004 (C�7 Name of Inspector: (Please Print) David D. Coughanowr,R.S: Company Name: Eco-Tech Environmental Mailing Address: 43 Triangle Circle Mashyee,MA 02563 Telephone Number: (508)364-0894 CERTIFICATION STATEMENT: I certify that I have personally inspected the sewage disposal system at this address and that the information reportedK below is true,accurate and complete as of the time of the inspection.The inspection was performed based on in training and experience in the proper function and maintenance of on-site sewage disposal systems;,I4am a DEP_ approved system inspector pursuant to section 15.340 of Title 5(310 CMR 15.000). The system` r� r_ X Passes Conditionally Passes r_ - Needs Further Evaluation By.the Local Approving Authority I �, Fails C:� C Inspector's Signature Cyr( Ch �S Date: �3Bv The System Inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority NOTES AND COMMENTS Inspector's Note—> A septic system is deemed to pass this Real Estate Transfer Inspection if it does not trigger any of the failure criteria listed below. The seC�tic system has been evaluated according to the conditions observed on the day it was inspected. No estimate or guaDantee of system longevity is made or implied by a passing determination. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 105 Berkshire Trail West Barnstable Owner: George&Nora Brown Date of Inspection: November 16, 2004 INSPECTION SUMMARY: Check A,B,C,D or E/ALWAYS complete all of section D: A] System Passes: Yes I have not found any information which indicates that any of the failure criteria described in 310 CMR 5.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. COMMENTS: B] System Conditionally Passes: One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes, no, or not determined(Y,N,or ND). in the for the following statements. If"not determined" please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not),is structurally unsound,exhibits substantial infiltration or exfiltration, or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or breakout or high static water level in the distribution box is due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. The system will pass inspection if(.with approval of Board of Health). broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced. ND explain The system required pumping more than four times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain 2 Page 3 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 105 Berkshire Trail West Barnstable Owner: George&Nora Brown Date of Inspection: November 16, 2004 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 and environment. 1 System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2) System will fail unless the Board of Health(and public water supplier,if any) determines that the system is functioning in a manner that protects the public health,safety,and environment The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis,performed by 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 I 3 Page 4 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 105 Berkshire Trail West Barnstable Owner: George&Nora Brown Date of Inspection: November 16, 2004 D) System Failure Criteria applicable to all systems: You must indicate either"yes" or"no"to each of the following for all inspections: I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this determination is identified below. The Board of.Health should be contacted to determine what will be necessary to correct the failure, yes no X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool. X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. X Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow. X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped X Any portion of the SAS,cesspool or privy is below high groundwater elevation. X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a,Zone 1 of a public well X Any portion of a cesspool or privy is within 50 feet of a private water supply well X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis.(This system passes if the well water analysis, performed by 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 the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well. If you have answered "yes" to any question in Section E the system is considered a significant threat,or answered "yes" in section D above the large system has failed. The owner or operator of any large system considered a significant threat under section E or failed under section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. 4 Page 5 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 105 Berkshire Trail West Barnstable Owner: George&Nora Brown Date of Inspection: November 16, 2004 Check if the following have been done: You must indicate either"Yes" or"No"as to each of the following: Yes No Y _ Pumping information was provided by the owner,occupant or Board of Health. N Were any of the system components pumped out in the last two weeks? Y _ Has the system received normal flows in the previous two week period? N Have large volumes of water been introduced to the system recently or as part of this inspection? Y _ Were as built plans of the system obtained and examined?(If they were not available as N/A) Y _ Was the facility or dwelling inspected for signs of sewage back-up? Y Was the site inspected for signs of breakout? Y _ Were all system components,excluding the SAS. located on site? Y Were the septic tank manholes uncovered, opened,and the interior of the septic tank inspected for the condition of the baffles or tees, material of construction,dimensions,depth of liquid, depth of sludge and depth of scum.? Y _ Was the facility owner(and occupants, if different from owner)provided with information on the proper maintenance of subsurface disposal systems? For information on the proper maintenance of subsurface disposal systems please go to: W W W.ECO-TECH.US The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Y Existing information. For example,Plan at the Board of Health. N Determined in the field(if any of the failure criteria related to part C is at issue,approximation of distance is unacceptable) [310 CMR 15.302(3)(b)] 5 Page 6 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 105 Berkshire Trail West Barnstable Owner: George&Nora Brown Date of Inspection: November 16, 2004 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 gpd Number of current residents 2 Does the 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): n/a Seasonal use(yes or no): no Water meter readings, if available(last two year's usage(gpd): n/a—well in use Sump Pump(yes or no): no Last date of occupancy: current C OMMERCIALANDUS TRIAL: Type of establishment: Design flow(based on 310 CMR 15.203):: gpd Basis of design flow(seats/persons/sgft/etc.): Grease trap present: (yes or no) Industrial waste holding tank present: (yes or no): Non-sanitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings, if available: Last date of occupancy/use:_ OTHER: (Describe): GENERAL INFORMATION PUMPING RECORDS Source of information: System last pumped in May 2003 (Owner) Was system pumped as part of the inspection: (yes or no) No If yes,volume pumped: gallons--How was quantity pumped determined? Reason for pumping: 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/Alternate technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight Tank Attach a copy of the DEP approval Other(describe) APPROXIMATE AGE of all components,date installed(if known)and source of information: Age: 12+years Certificate of Compliance issued 9/15/92(BOH permit#92-352) Were sewage odors detected when arriving at the site: (yes or no) no 6 Page 7 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 105 Berkshire Trail West Barnstable Owner: George&Nora Brown Date of Inspection: November 16, 2004 BUILDING SEWER_(Locate on site plan) Depth below grade: 1 It Material of construction:—cast iron X 40 PVC_other(explain) Distance from private water supply well or suction line 20+ Comments: (on condition of joints,venting, evidence of leakage, etc.) Sewer is vented through roof and appears structurally sound with no evidence of leakage or backup into dwelling_ SEPTIC TANK:Yes (locate on site plan) Depth below grade: 6 inches Material of construction: X concrete_metal_fiberglass polyethylene other(explain) If tank is metal,list age_ Is age confirmed by Certificate of Compliance_(yes or no):_(attach a copy of certificate) Dimensions: 8.5 ft x 5 ft x 5 ft(1000 gallon) Sludge depth: 4 in Distance from top of sludge to bottom of outlet tee or baffle: 30 in Scum thickness: 1 in Distance from top of scum to top of outlet tee or baffle: 9 in Distance from bottom of scum to bottom of outlet tee or baffle: 14 in How dimensions were determined: Probe to top of tank Comments: (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc.): Pumping not required at this time but maintenance pumping is recommended within and evM 2 years. Liquid level at outlet invert. Tank and tees appear structurally sound and functioning as intended. No evidence of leakage in or out. GREASE TRAP: none (locate on site plan) Depth below grade: Material of construction: concrete_metal_fiberglass polyethylene other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle:_ Date of last pumping: Comments: (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 105 Berkshire Trail West Barnstable Owner: George&Nora Brown Date of Inspection: . November 16, 2004 TIGHT OR.HOLDING TANK: none (Tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete_metal _fiberglass polyethylene other(explain) Dimensions: Capacity: gallons Design flow: _gallons/day Alarm present(yes or no): Alarm level: _ Alarm in working order(yes or no):_ Date of last pumping: Comments:(condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX:yes (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: at outlet inverts Comments:(note if.box is level and distribution to outlets is equal,any evidence of solids carryover,any evidence of leakage into or out of box, etc.) D-box appears structurally sound with no evidence of leakage in or out.Effluent level at outlet inverts. Few solids in sump. PUMP CHAMBER: none (locate on site plan) Pumps in working order: (yes or no) Alarms in working order: (yes or no) Comments(note condition of pump chamber,condition of pumps and appurtenances, etc.): 8 Page 9 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 105 Berkshire Trail West Barnstable Owner: George&Nora Brown Date of Inspection: November 16, 2004 SOIL ABSORPTION SYSTEM(SAS): Yes (locate on site plan;excavation not required) If SAS not located, explain why: Type: X leaching pits,number 2 _leaching chambers,number _leaching galleries,number _leaching trenches, number,length _leaching fields,number,dimensions _overflow cesspool, number —innovative/alternate system Type/name of Technology Comments: (note condition of soil, signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.) Soils above leaching pits appeared unsaturated. No evidence of surface ponding breakout,lush vegetation or other evidence of hydraulic failure was observed. A 5 gallon bucket of water was poured into the distribution box and was observed to flow freely out and was heard splashing down into leach pits. CESSPOOLS: none (cesspool must be pumped at time of inspection)(locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments: (note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation, etc.): PRIVY: none (locate on site plan) Materials of construction: Dimensions:_ Depth of solids: Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.): I 9 Page 10 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 105 Berkshire Trail West Barnstable Owner: George&Nora Brown Date of Inspection: November 16, 2004 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'(Locate where public water supply enters the building) LOCATIONS A B C LEPACH 1 17.5 f t 38 f t 2 13 ft 54 ft 3 21 ft 41 ft SEPTIC 4 33 f t 62.5 f t LEACH TANK PIT 20 D-BOX o 0 A g EXISTING DWELLING # 105 A WELL z BERKSHIRE TRAIL NOT TO SCALE 10 Page 11 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 105 Berkshire Trail West Barnstable Owner: George&Nora Brown Date of Inspection: November 16, 2004 SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to ground water: 100+ feet Please indicate(check)all methods used to determine high ground water elevation: Obtained from system design plans on record-If checked. date of design plan reviewed Observed Site(abutting property/observation hole within 150 feet of SAS) X Checked with local Board of health-explain: GIS records Checked local excavators, installers-attach documentation) Accessed USGS database You must describe how you established the high ground water elevation. Barnstable GIS Department records indicate that this property is over 100 feet above groundwater table. 11 TOWN OF BARNSTABLE G LOCATION ��� p&YkS4rre (m I _ SEWAGE # `2' 35 Z W PSt tr Kftti y!e ASSESSOR'S MAP & LOT t 1 10 INSTALLER'S NAME&PHONE NO. Too 't 4a 1TU SEPTIC TANK CAPACITY (00011,1 LEACHING FACILITY: (type) Z (size) lZ X 6 NO.OF BEDROOMS 3 BUILDER OR OWNER Gee, ^?e 1 Jo flow PERMTTDATE: 4r 15jq Z- COMPLIANCE DATE: Cf Sl Z Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Od} Feet Private Water Supply Well and Leaching Facility (If any wells exist QUO+ 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;CO-Teck Cwv-1oh m.e,4A/ LOCATIONS A B C LEACH PIT 1 17.5 ft 38 ft 2 13 ft 54 ft 3 21 ft 41 ft SEPTIC 4 33 f t 62.5 f t LEACH TANK PIT 2❑ D-BOX o I A EXISTING e DWELLING # 105 WELL BERKSHIRE TRAIL NInT T(") TOWN OF BARNSTABLE LOCATION l f i f r k5kh 't SEWAGE VILLAGE / �J4✓1� .rf���e ASSESSOR'S MAP & LOT` I::i-0 15- CQ INSTALLER'S NAME & PHONE NO. J'®h�j SEPTIC TANK CAPACITY A200=; LEACHING FACILITY:(type) a - Lp (size) `4 . NO. OF BEDROOMS f " RIVATE WELDOR PUBLIC WATER BUILDER OR OWNER Ali k�jG,/ A1,104-1-j DATE PERMIT ISSUED: -21 e DATE COMPLIANCE ISSUED: �- VARIANCE GRANTED: Yes No YY 10 No.. �..._ .. Fss..... .._...._ P ® THE COMMONWEALTH OF MASSACHUSETTS �� I 'BOARD OF HEALTH _ ICJ ........OF........ . - Appl ration for Diupuuttl Works Tonutrurtiun Permit Application is hereby made for a Permit to Construct (-/or Repair ( ) an Individual Sewage Disposal System at: - ................__....t_Z /.. J uGs ff r fZE ``�I L....... - ........................ Location-Address or Lot No. ................_.....��L.c.�..� v .. ..j6h). t'?--- ------------------------------------------ --- -----------------------•---------.---------- �' "ner Address a ...:......... .4.1. --- - -Z/ ............................... .....--------•-•-•-•..__._._...-••----....__------•--•--........----------•--'---................_ Installer Address Type of Building Size Lot............................Sq. feet ., Dwelling—No. of Bedrooms______________ ___________________________Expansion Attic ( ) Garbage Grinder ( ) `4 Other—Type of Building No. of ersons____________________________ Showers W YP g -------------•-•---••------- P ( ) — Cafeteria ( ) a' Other fixtures ..................................... W Design Flow............l__1.0............... �} gallons per pemon- er day. Total daily flow........ ...................gallons., WSeptic Tank—Liquid capacityj (J.gallons Length... Width:q._LU__ Diameter________________ Depth.r5_�_. x Disposal Trench—No_ ____________________ Width.................... Total Length.................... Total leaching area.................._sq. ft. 3 Seepage Pit No______ ___....... Diameter.._._{_ —._. Depth below inlet.._ Total leaching area_. ..sq. ft. z Other Distribution box CNvQ Dosing tank ( ) Percolation Test ResyU5 Performed by........Z) ... 4............... Date...... ...L ....... . Test Pit No. i__/_..._L__—_....minutes per inch Depth of Test Pit...... ..,Depth to ground water__ 44 Test Pit No. 2...� Z. -minutes per inch Depth of Test Pit........ . _ . Depth to ground water........................ R; ......................................---• ...._........__......----•-- - ... - ._.........._...... O Description of Soil............. ... �� __ M -•----.....--••............................� :_._7v�......................._:_::_:__............::::_ ................ :: W 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.:I'LU 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been Aped by the board of health. Signed)(..... ...............•____ ............................. Date Application Approved BY ----- _ :-.�. � ........ . Date Application Disapproved for the following reasons:............................................................................................................ ....-•---•.............................--p----•--•-------------...--•••-••...•---•.........._._.._.._.........._..---•••-••-•--•••-••-•••------•--•--.._..-••---•._......--•••-.... .................... Date Permit No......1.AL._::...`�512................... Issued..................____-_----------- ._............ ..» . Date F hp..4� THE COMMONWEALTH OF MASSACHUSETTS VEz............ 0 BOARD OF HEALTH -7-27U)t\)........OF........ ------- .....I...... ........................ Appliration for Disposal Works Tonstrurtion Permit 0') f Application is hereby made for a Permit to Construct (-/) or Repair an Individual Sewige Disposal System at: I C�o 3 .... ........................................ L-or...... 3c>t K.S(f/.(Zc....... ............... .......................... Location-Address or ..................... (A... ... ............................................................................................... 0%3ner Address ............................... ................................................................................................... Installer Address Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms.............. >---------_--_---------Expansion Attic Garbage Grinder 04 Other—Type of Building ............................ No. of persons._.........._............._. Showers Cafeteria 04 Other fixtures .................................... .................................................................................................... Wd Design Flow............410............... 'gallons per per-son-per day. Total daily flow........_'?;_0..................gallons.,, Septic Tank—Liquid capacity/h—,) gallons Length-- 0"Diameter................ Depth.4_.(...(,.( Disposal Trench—No..................... Width..__........._...... Total Length.................... Total leaching area..............::._..sq. ft. Seepage Pit No.._...al. ..... Diameter..... Depth below inlet....6.1......... Total leaching area..'t? L/ sq. ft. Z Other Distribution box (,lv,) Dosing tank 0-4 a. t.!z��-JAU...f ft.;.(2 ....ic............... Date...... /I f Percolation Test Res I Performed by........ A -------------- ....minutes per inch Depth of Test Depth to ground wate Test Pit No. L. Pit__._.__.J.Y:�f_4 fl, Test Pit No. 2...4-2--minutes per inch Depth of Test Pit........ Depth to ground water......................... .................*------------------------------------­........................................................................................... 0 Description of Soil............. ..i..1r*.......le�2. ..... ---------------­­------*------------------------ -------------­....... ------*-------------- ------------- ................................................................. ------------------­.........**------------ .....................................................................................................................7.................................................................................. U Nature of Repairs or Alterations—Answer when applicable...............;------------- Z.................................................... ............................................ .......................................................................................................................................................... Agreement: I The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of T I T I.E. 5 of the State Sanitary Code— The undersigned further agrees not to place the system in 'operation until a Certificate of Compliance has been iss I ued by the board of health. Signed ................................................................................ ............................. Date Application Approved By...............Kj­.:_....._. ................................... .... ..... � Date Application Disapproved for the following reasons:............................................................................................................ ....................................................................................................................................................................................................... Date PermitNo.... .................... Issued....................................................... Date ..............-----------------­ .................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ........OF......... ..................................... Trrtifiratp of Tomplianve THIS IS TO CE%IFY, That the Individual Sewage Disposal System constructed (X) or Repaired by ........ ............................................................................................................................................. at ...................... .................. ....... ....tj 4�t4-41. .. ......................................... . ... .................I...... 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 FUNCTION SATISFACTORY. DATE............................ ......"...........;............................ Inspector............... -------------------*--------*------.......... ---------- ------------ ---------_ THE COMMONWEALTH OF MASSACHUSETTS BOARD 6OF HEALTH ........OF............. .... . L. . .......................... Disposal Works Tonstrurtion Permit Permission is hereby granted- - ...6.nP.46.y....................................................................................... ---------Individual 4-------- -- -- to Construct or Repair ( an Ifidividual Sewage Disposal System atNo............. ......./�.......................11.......t...... ........................................................................................... /­11 Street as shown on the application for Disposal Works Constructi ......... .......... �rwv ..,ie rmit N ed..... .. ...... Vt DATE............... 16m 7­ ........................................ ENVIROTECH LABORATORIES Mass. Cert. #:MA063 449 Route 130 Sandwich, MA 02563 • (508) 888-6460 CLIENT: _ Larry Nickukus LOCATION: Lot 15 Berkshire Trails ADDRESS: W. Barnstable, MA COLLECTED BY: L.Wile SAMPLE DATE: 6-23-92 TIME: DATE RECEIVED: 6-23-97SAMPLE ID: Z629 JOB #: New Well WELL DEPTH: 160'4" RESULTS OF ANALYSIS: Parameter Units Recommended limit Result Coliform bacteria/100 ml (MF Method) 0 0 pH pH units 6.0-8.5 6.96 Conductance umhos/cm 500 304 Sodium mg/L 20.0 42.5 Nitrate-N mg/L 10.0 0.27 Iron mg/L 0.3 0. 13 Manganese mg/L 0.05 0.08 Hardness mg/L as CaCO3 500 46.6 Sulfate mg/L 250 5.8 Potassium mg/L 20.0 0.7 Alkalinity mg/L 200 12.0 Chloride mg/L 250 12. 1 Turbidity NTU 5.0 15.9 Color APC units 15.0 3.0 Background bacteria COMMENT: Sodium level is not a health- hazard, but if on a low sodium diet, consult physician before drinking. EPA 601/602* ug/L Below[ ❑ Re rtin Limit ym NO WATER IS SUITABLE FOR DRINKING PURPOSES FOR PA /METERS TESYED. X * See Attached Report � -� DATE �L ax ANALYTICAL EPA METHODS 501 and 502 Volatile Organics (GC/PID/ELCD) Field ID: Z629 Lab ID: 3362-01 f Project: Nickulas Batch ID: VHA-1014-W ,. Client: Envirotech Laboratories Sampled: 06-23-92 l Cont/Prsv: 40ml VOA Vial/NaHSO4 Cool Received: 06-26-92 Matrix: Aqueous Analyzed: 07-01-92 t y PARAMETER CONCENTRATION REPORTING LIMIT t (ug/L) (ug/L) 'i S Dichlorodifluoromethane BRL 5 Chloromethane BRL I Vinyl Chloride BRL 1 Bromomethane BRL 5 Chloroethane BRL 1 Trichlorofluoromethane BRL 1 l,l-Dichloroethene BRL 1 Methylene Chloride BRL I trans-1,2-Dichloroethene BRL 1 1,1-Dichloroethane BRL 1 cis-1,2-Dichloroethene * BRL I Chloroform BRL 1 1,1,1-Trichloroethane BRL I Carbon Tetrachloride BRL 1 Benzene BRL 1 1,?-Dichloroethane BRL 1 Trichloroethene BRL 1 1,2-Dichloropropane BRL I Bromodichloromethane BRL 1 2-Chloroethylvinyl Ether BRL 1 trans-1,3-Dichloropropene BRL 1 Toluene BRL 1 cis-1,3-Dichloropropene BRL 1 1,1,2-Trichloroethane BRL 1 Tetrachloroethene BRL 1 Dibromochloromethane BRL 1 Chlorobenzene BRL 1 Ethylbenzene BRL m+pp-Xylene * BRL 1 o-Xylene * BRL 1 Bromoform BRL I 1,1,2,2-Tetrachloroethane BRL 1 1,3-Dichlorobenzene BRL 1 1,4-Dichlorobenzene BRL 1 1,2-Dichlorobenzene BRL 1 QC SURROGATE COMPOUND SPIKED MEASURED RECOVERY QC LIMITS f Bromochloromethane 30 31 103 % 83 - 117 % { Fluorobenzene 30 30 102 % 87 - 113 % BRL = Below Reporting Limit. Non-target compound. "Trace" indicates probable presence below listed Reporting Limit. Method References: Method 601 - 7urgeable Halocarbons and Method 602 - Purgeable Aromatics, 40 C.F.R. 136, Appendix A (1986). - I ub tSemsnlre I rail basement Flan 28FT 15 FT �• m 14ft 7 Laundryroom & Storage o N' N 5 ft 6" ., co C6 �� 13ft 8" 5ft 6.5 oa opening r'J- 8ft 32 F 0'�� 4ft s� y J a CD X - 4ra w 0 s a° N ° Ctt fQ . 3599 rough open CD CD Utility Room ,.} x F•3 �o o I � o cn to s ` existing window # 3 r i-� -- ------ No. -=---------------- Fee-� � BOARD OF HEALTH TOWN OF BARNSTABLE Application-*rVell C 5tructiottpermit Application is hereby made fora rmit to Construct ( ), Alter ( ), or Repair ( )an individual Well at: - ----- 1 - QR - - - -- --- - -- - --- ------------------------------ Locatio — ddress Assessors Map and Parcel V �l rr r���u -----:& ---- Q- --' ------ ------------------------------------------------ - - Ow r Add'ss Install, — Driller Address — Type of Building Dwelling-------------------------------------------------------------- Other - Type of Building No. of Persons--------------------------------------------------- c{ Type of Well- Qy - Capacity- -- ------------------------------------------------------------ Purpose of Well---- - -------------------— -- 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 Certificate of Compliance has been issued by the Board of Health. Sign, - - -- LS.c ---- - ---------------------------------- date J. -- Application Approved By----- - ----- ------- ----------------------__ __��___ �`r�_� date Application Disapproved for the following reasons:----------------------------------------- __.__-__---_------------------ --------------------------------------------- — ------------------------------------------------------ date Permit No. - ---- - ----------------- Issued---------- - ------------ date BOARD OF HEALTH TOWN OF BARNSTABLE (Certificate ®f (Comphance THIS IS TO C RTIFY, hat the Individual Well Constructed ( Altered ( ), or Repaired ( ) `--- -- -------------------------- ---- -- ---------------------- -------------------------------------------------------------------------- j Installer a - ------ -- --_- _ -- --_ has been installed in accordance with the provisions of the Town of Barnsst�ablle Board of Health Private Well Protection Regulation as described in the application for Well Construction Pert�iP o - Dated THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL F NCTION SATISFACTORY. DATEi/ ----------------------------------------------------- Inspector----------------— -- - --- - —� Fee- -- =-'�'"--"''------�--�-") BOARD OF HEALTH TOWN OF BARNSTABLE ' citation-*rVerr "."ruction Permit Application is hereby made fora Jermit to Cons ruct ( ), Alter ( ), or Repair ( )an individual Well at: ------------------------------------------------------------------------------------- ---- --------------- Location — Address Assessors Map and Parcel r41^!^ �1�---- L -- - �- ---or ----- ----------------------------------------------------I------------- --------- - - - Owner Installer'— Driller � Address Type of Building Dwelling------------------------------------------------------------------ Other - Type of Building------------------------------------ No. of Persons--------------------------------------------------------- �r . Typeof Well---_�.-r-_--....PLC---- ---------------------------------------- Capacity---------------------------------------------------------------------------------- Purpose of Well---- , ----------------------------------- + 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. Signe-A _ _________- ____________ _. date � Application Approved By---- date Application Disapproved for the following reasons:------------------------__________________________________—__------—--------_-------_--------- -------------------------------------------------------- ---------------------------------—---------- — -- ----------- -- —a- - --Permit No.-- ° -- - Issued----------- `fir -'r! ------------ — date , r" BOARD OF HEALTH ` TOWN OF BARNSTABLE (Certificate ®f (Compliance THIS IS TO CERTIFY, That the Individual Well Constructed Altered ( ), or Repaired ( ) by ----- "' -h '--— - -- - - - -------------------------------------------------------------------- --------------------------- Installer aj'0`rt` ------- - ' - ` t1 - 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 Dated THE JSSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT.THE WELL SYSTEM WILL FUNCTION SATISFACTORY. rn DATE-�1--11-- --r�-------------------------------—----------------- Inspector-------------------------------- .--------------------------------------- 6 f *' BOARD OF HEALTH TOWN OF BARNSTABLE Yell (fongtructionPermit 4.t --'----� No. --, -- ��- Fee Permission is hereby granted�u-=--&;IJ----- = - ------------------ --------------------------------------------------- to Construct ((/Alter ( ), or Repair ( ) an Individual Well at: d No. - - -- -s" --------------------------------- -------- ---- ------------ Street as shown on the application'for a Well Construction Permit No.--- -------------------------- Dated---------- ----------------------- r -' ----------------------- Board of Health DATE------ ----�� -------- ..: ... .s.. 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