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COMMON W FAIL J I OF MASSACHUSETTS
_ = EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ElNVI:RONMENTAL. PROTECTION
ONE WINTER STREET, BOSTON MA 02108 (617) 292-5500
TRUDY COXE
350 MAIN STREET Secretary
ARGEO PAUL CELLUCCI WEST YARMOUTH, MA DAVID B. STRURS
Governor 508-775-2800 Coninussioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
MAP 109 PAR 015
PROPERTY ADDRESS: 150 BERKSHIRE TRAIL,W. BARNSTABLE ADDRESS OF OWNER:
DATE OF INSPECTION: AUGUST 24, 2000 PAUL HAYDON
NAME OF INSPECTOR : RICHARD K. CANNON
am a DEP approved system inspector pursuant to Section 15.340 of Title 5 9310 CMR 15.000)
COMPANY NAME: A&B Canco
MAILING ADDRESS: 350 Main Street,West Yarmouth,MA 02673
TELEPHONE NUMBER: (508)775-2800
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:
X PASSES
CONDITIONALLY PASSES
NEEDS FURTH R E LU I N BY THE LOCAL APPROVING AUTHORITY
FAILS
INSPECTORS SIGNATURE: DATE: AUGUST 30,2000
The system Inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP) 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 system owner and copies sent to the buyer,if applicable and the approving authority.
NOTES AND COMMENTS:
SITE OVER ALL PASSES,INSPECTION OF SYSTEM IS BASED ON CONDITION OF SYSTEM AT THE TIME
OF THE INSPECTION.THERE IS NO GUARANTEE ON THE LIFE OF THE SYSTEM.
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revised 9/2/98
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIVICATION (continued)
Property Address: 150 BERKSHIRE TRAIL,WEST BARNSTABLE
Owner: HAYDON, PAUL
Date of Inspection: AUGUST 29,2000
INSPECTION SUMMARY: Check A, B, C, orD:
A] SYSTEM PASSES: X
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.
COMMENTS:
B SYSTEM CONDITIONALLY PASSES: N/A
One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The
System,upon completion of the replacement or repair,as approved by the Board of Health will pass.
Indicate yes,no,or not determined(Y,N,or ND). Describe basis of determination in all instances. If"not determined",explain why not)
The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate
Of Compliance(attached)indicating that the tank was installed within twenty(20) years prior to the date of the
inspection;or the septic tank,whether or not metal,is cracked,structurally unsound,shows substantial infiltration or
exfiltration,or tank is 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.
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed
pipe(s)or due to a broken,settled or uneven distribution box. The system will pa
pass inspection if(with approval of the Board of Health).
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
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
p
revised 9/2/98 2
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 150 BERKSHIRE TRAIL,WEST BARNSTABLE
Owner: HAYDON, PAUL
Date of Inspection: AUGUST 29,2000
C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: N/A
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 HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303
(1)(b)THT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY
AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of 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 AND
SAFETY AND THE ENVIRONMENT:
The system has a septic tank and soil absorption system(SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
The system has a septic tank and soil absorption system and the SAS is within a Zone
1 of a public water supply well.
The system has a septic tank and soil absorption system and the SAS is within 50 feet
of a private water supply well.
The system has a septic tank and soil absorption system and the SAS is less than 100
feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility
and the presence of ammonia nitrogen and nitrate nitrogen and is equal to or less than 5 ppm. Method
used to determine distance (approximation not valid).
3) OTHER
revised 9/2/98 3
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 150 BERKSHIRE TRAIL
Owner: HAYDON, PAUL
Date of Inspection: AUGUST 29,2000
D]SYSTEM FAILS: N/A
You must indicate either"Yes"or"No" to each of the following:
I have determined that one or more of the following failure conditions exist as described in 310 CMR
16.303. 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
Backup of sewage into facility or system component due to an overloaded or clogged
SAS or cesspool.
Discharge or ponding of effluent to the surface of the ground or surface waters due to an over-
loaded or clogged SAS or cesspool.
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged
SAS or cesspool.
Liquid depth in cesspool is less than 6"below invert or available volume is less than 1%day flow
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 Soil Absorption System,cesspool or privy is below the high groundwater
elevation.
Any portion of a cesspool or privy is within 100 feet of surface water supply or tributary to a
surface water supply.
Any portion of a cesspool or privy is within a Zone I of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private
water supply well with no acceptable water quality analysis. 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: N/A
You must indicate either"Yes"or"No"as to each of the following:
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a
significant threat to public health and safety and the environment because one or more of the following conditions exist:
Yes No
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
mapped Zone II of a public water supply well)
The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local
regional office of the Department for further information.
revised 9/2/98 4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 150 BERKSHIRE TRAIL,WEST BARNSTABLE
Owner: HAYDON, PAUL
Date of Inspection: AUGUST 29, 2000
Check if the following have been done:You must indicate either"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 None of the system components have been pumped for at least two weeks and the system
has been receiving normal flow rates during that period. Large volumes of water have not been introduced into
the system recently or as part of this inspection.
X As built plans have been obtained and examined. Note if they are not available with N/A.
X The facility or dwelling was inspected for signs of sewage back-up.
X The system does not receive non-sanitary or industrial waste flow.
X The site was inspected for signs of breakout.
X All system components,including the Soil Absorption System,have been located on the site.
X The septic tank manholes were uncovered,opened,and the interior of the septic tank was
inspected for condition of baffles or tees,material of construction,dimensions,depth of liquid
depth of sludge,depth of scum. The size and location of the Soil Absorption System on the site
Has been determined based on:
X Existing information.Ex.Plan at B.O.H.
X Determined in the field(if any of the failure criteria related to Part C is at issue,approximation
of distance is unacceptable)[15.302(3)(b)]
X The facility owner(and occupants,if different from owner)were provided with information on
the proper maintenance of Sub-Surface Disposal System.
revised 9/2/98 5
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 150 BERKSHIRE TRAIL,WEST BARNSTABLE
Owner: HAYDON, PAUL
Date of Inspection: AUGUST 29,2000
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 330 g.p.d./bedroom for S.A.S.
Number of bedrooms(design) 3 Number of bedrooms(actual): 3
Total DESIGN flow
Number of current residents: 4
Garbage grinder(yes or no): NO
Laundry(separate system) (yes or no): NO If yes,separate inspection required
Laundry system inspected(yes or no): YES
Seasonal use(yes or no) NO
Water meter readings,if available(last two(2)year usage(gpd): WELL WATER
Sump Pump(yes or no): NO
Last date of occupancy: N/A
COMMERCIAL/INDUSTRIAL:
Type of establishment:
Design flow: Gpd(Based on 16.203)
Basis of design flow
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:
OTHER:(Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
N/A
System pumped as part of inspection:(yes or no) NO
If yes,volume pumped: gallons
Reason for pumping
TYPE OF SYSTEM
X Septic tankidistribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no)(if yes,attach previous inspection records,if any)
VA Technology etc.Attach copy of up to date operation and maintenance contract.
Tight Tank Copy of DEP Approval
Other
APPROXIMATE AGE of all components, date installed (if known) and source of information:
1991 PERMIT#91-533
Sewage odors detected when arriving at the site:(yes or no) NO
revised 9/2/98 6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 150 BERKSHIRE TRAIL,WEST BARNSTABLE
Owner: HAYDON, PAUL
Date of Inspection: AUGUST 29,2000
BUILDING SEWER: N/A
(Locate on site plan)
Depth below grade:
Material of construction _ cast iron _ 40 PVC _ other(explain)
Distance from private water supply well or suction line
Diameter
Comments:(condition of joints,venting,evidence of leakage,etc.)
SEPTIC TANK: X
(Locate on site plan)
Depth below grade: 181,
Material of construction X concrete _ metal _ Fiberglass _ Polyethylene _ other(explain)
If tank is metal,list age Is age confirmed by Certificate of Compliance (Yes/No)
Dimensions: 1,000 GALLON
Sludge depth: 2"
Distance from top of sludge to bottom of outlet tee or baffle: 28"
Scum thickness:
Distance from top of scum to top of outlet tee or baffle: 1"
Distance from bottom of scum to bottom of outlet tee or baffle: 12"
How dimensions were determined ASBUILT AND TAPE
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.)
MAIN TANK IS 18"BELOW GRADE,BOTH COVERS 18"BELOW GRADE,OUTLET HAS BAFFLE IN PLACE.
GREASE TRAP: N/A
(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:
(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 9/2/98 7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 150 BERKSHIRE TRAIL,WEST BARNSTABLE
Owner: HAYDON, PAUL
Date of Inspection: AUGUST 29,2000
TIGHT OR HOLDING TANK: N/A (Tank must be pumped prior to,or 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
Alarm level: Alarm in working order Yes; No
Date of previous pumping:
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
DISTRIBUTION BOX: X_
(locate on site plan)
Depth of liquid level above outlet invert: 0
Comments:
(note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc,)
D-BOX IS 30"BELOW GRADE WITH ONE INLET.ONE OUTLET. THE BOX IS 16"X16",BOX IS LEVEL AND CLEAN.
PUMP CHAMBER: N/A
(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.)
revised 9/2/98 8
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 150 BERKSHIRE TRAIL,WEST BARNSTABLE
Owner: HAYDON, PAUL
Date of Inspection: AUGUST 29, 2000
SOIL ABSORPTION SYSTEM (SAS): X
(locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods)
If not located, explain:
Type:
Leaching pits,number: 1
Leaching chambers,number:
Leaching galleries,number:
Leaching trenches,number,length:
Leaching fields,number,dimensions:
Overflow cesspool,number,
Alternative system:
Name of Technology:
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.)
LEACHING IS ONE(1)PRE CAST PIT.6"X12",COVER IS 6"BELOW GRADE. PIT HAS 3'WATER AT TIME OF INSPECTION.
CESSPOOLS: N/A
(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(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: N/A
(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.)
revised 9/2/98 9
x
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 150 BERKSHIRE TRAIL, WEST BARNSTABLE
Owner: HAYDON, PAUL
Date of Inspection: AUGUST 29, 2000
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'(locate where public water supply comes into house)
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revised 9/2/98 10
R SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 150 BERKSHIRE TRAIL, WEST BARNSTABLE
Owner: HAYDON, PAUL
Date of Inspection: AUGUST 29, 2000
NRCS Report name
Soil Type
Typical depth to groundwater
USGS Date website visited
Observation Wells checked
Ground water depth: Shallow Moderate Deep
SITE EXAM Slope
Surface water
Check Cellar
Shallow wells
Estimated Depth to groundwater Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
X Observation of Site(Abutting property,observation hole,basement sump etc.)
Determine it from local conditions
Check with local Board of health
Check FEMA Maps
Check pumping records
Check local excavators,installers
Use USGS Data
Describe in your own words how you established the High Groundwater Elevation.(Must be completed)
AREA OFF CEDAR STREET, AREA HIGH.
revised 9/2/98 11
Commonwealth of Massachusetts o &S- 0001
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
150 Berkshire Trail w
Property Address Wti
Richard Haydon
Owner Owner's Name '
information is West Barnstable ✓ Ma. 02668 7/20/2018
required for every
page. City/Town State Zip Code Date of Inspection 'Xi
i
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When A. General Information
filling out forms 5
on the computer, I
use only the tab 1. Inspector:
key to move your
cursor-do not Sean M. Jones
use the return Name of Inspector
key.
S.M.Jones Title V Septic Inspection
Q Company Name
74 Beldan Lane
Company Address
Centerville Ma 02632
City/Town State Zip Code
774-248-4850 smjonestitle5@gmail.com S14522
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 16.340 of
Title 5(310 CMR 15.000). The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
7/20/2018
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 should be sent to the system owner and copies sent to the
buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins.doc•rev.6i16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17
cam, Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
u
150 Berkshire Trail
Property Address
Richard Haydon
Owner Owner's Name
information is required for every West Barnstable Ma. 02668 7/20/2018
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
The dwelling located at 150 Berkshire Trail West Barnstable is served by a Title V septic system
consisting of a 1000 gallon septic tank, distribution box and a 1000 gallon precast leaching pit.
The system was found to be in proper working condition at the time of inspection.
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no"or"not determined (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
i� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
a
150 Berkshire Trail
Property Address
Richard Haydon.
Owner Owner's Name
information is required for every West Barnstable Ma. 02668 7/20/2018
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
c Commonwealth of Massachusetts
j = Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
150 Berkshire Trail
Property Address
Richard Haydon
Owner Owner's Name
information is required for every West Barnstable Ma. 02668 7/20/2018
page. Cityfrown State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than '/day flow
t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
150 Berkshire Trail
Property Address
Richard Haydon
Owner Owner's Name
information is required for every West Barnstable Ma. 02668 7/20/2018
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 16,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins.doc•rev.6/16 Title,5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
t.
150 Berkshire Trail
Property Address
Richard Haydon
Owner Owner's Name
information is required for every West Barnstable Ma. 02668 7/20/2018
page. City[Town State Zip Code Date of Inspection
C. Checklist
Check if the.following have been done. You must indicate"yes" or"no" as to each of the following:
Yes No
❑ ® Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS)on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 gpd
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
u
150 Berkshire Trail
Property Address
Richard Haydon
Owner Owner's Name
information is required for every West Barnstable Ma. 02668 7/20/2018
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 2
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available(last 2 years usage(gpd)): well
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: current
Date
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
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
150 Berkshire Trail
Property Address
Richard Haydon
Owner Owner's Name
information is required for every West Barnstable Ma. 02668 7/20/2018
page. City(rown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
150 Berkshire Trail
Property Address
Richard Haydon
Owner Owner's Name
information is required for every West Barnstable Ma. 02668 7/20/2018
page. City(rown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
1/9/92 per town records
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 2
feet
Material of construction:
❑ cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
Joints ok, no leaks , vented through roof
Septic Tank(locate on site plan):
Depth below grade: 1.5
feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1000 gallons
Sludge depth:
6"
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
I a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
150 Berkshire Trail
Property Address
Richard Haydon
Owner Owners Name
information is required for every West Barnstable Ma. 02668 7/20/2018
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
3'
Scum thickness
3"
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
10"
How were dimensions determined? opened covers and took
measurements
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 does not need to be cleaned now but should be done soon and again every 2 years for proper
maintenance. water level was even with outlet, tank was not leaking and was structurally sound. Inlet
cover is on a riser
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
i1� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
150 Berkshire Trail
Property Address
Richard Haydon
Owner Owner's Name
information is required for every West Barnstable Ma. 02668 7/20/2018
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
150 Berkshire Trail
Property Address
Richard Haydon
Owner Owner's Name
information is required for every West Barnstable Ma. 02668 7/20/2018
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
OilDepth of liquid level above outlet invert
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
Distribution box was in good condition, no rot, water level was even with outlet invert.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
150 Berkshire Trail
Property Address
Richard Haydon
Owner Owner's Name
information is required for every West Barnstable Ma. 02668 7/20/2018
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: 1x1000 gals
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Leach pit was found to have 2.5' standing water at time of inspection. Due to depth of pit a stain line
was not able to be observed. Pit cover is on a 7' riser at grade.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
�n Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
150 Berkshire Trail
Property Address
Richard Haydon
Owner Owners Name
information is required for every West Barnstable Ma. 02668 7/20/2018
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
150 Berkshire Trail
Property Address
Richard Haydon
Owner Owner's Name
information is required for every West Barnstable Ma. 02668 7/20/2018
page. City/town State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
t: , V
t d
2 �
Arf 22
3
.A2 76(6
fS'Z 3SC,
A3 3b
70�
fay
t5ins.doc•rev.6/16 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 15 of 17
M1
Commonwealth of Massachusetts
n Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
150 Berkshire Trail
Property Address
Richard Haydon
Owner Owners Name
information is West Barnstable Ma. 02668 7/20/2018
required for every
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: 12+
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
` ❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Property is elevated compared to surrounding area.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
rah Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
150 Berkshire Trail
Property Address
Richard Haydon
Owner Owner's Name
information is required for every West Barnstable Ma. 02668 7/20/2018
page. Citylrown State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
' I
o� CERTIFICATE OF ANALYSIS
Barnstable County Health Laboratory (M-MA009)
Recipient: Order No.: G18108644
Paul Haydon Report Dated: 08/06/2018
150 Bershire Trail Submitter. Paul Haydon
W Barnstable, MA 02668 Description: rtn+voc
Laboratory ID#: 18108644-01 Matrix: Water-Drinking.Water
Sample#: Sampled: 07/25/2018 10:20 By: Paul
Collection Address: 150 Berkshire Trait,W Barnstable Received: 07/25/2018 15:40 By: Thiago
Sample Location: Turn Around: Standard
Routine
ITEM RESULT UNITS RL MCL METHOD# ANALYST TESTED TIME
Nitra.te.as Nitrogen 1.0 mg/L 0.10 10 EPA 300.0 LAP- 0712612018 7:37
Copper 0.46 mg/L 0.10 1.3 SM 3111E - LAP 07/27/2018 1.1:00
Iron ND mg/L 0.10 0.3 SM 3111E LAP 07/27/2018 11:00
pH 6.2 PH AT 25C NA 6.5-8.5 SM 4500-H,6 DCB 07/25/2018 15:53
Sodium 30 mg/L .2.5 20 SM 3111 B LAP 07/27/2018 11:00
Total Coliform Absent P/A 0 0 SM 9223E RG 07/25/2018 16:40
Conductance 270 umohs/cm 2.0 EPA 120.1 DCB 07/25/2018 15:53
Sodium level is above the maxium contaminant level. Those on a low sodium diet may wish to consult a physician.
_... _. _.. _. ._.__ __...... - --- --- -- -- --- --- �_ __....._. ._ - __... ------ --- __
Aft ached please find the laboratory certified parameter list.
Appro 1.ved
(Lab Director)
ND=None Detected RL = Reporting Limit MCL=Maximum Contaminant Level
319.5 Main Street, PO. Box 427, Barnstable; MA 02630 Ph: 508-375-6605 Page: 1 of 1.
CERTIFICATE OF ANALYSIS
Barnstable County Health Laboratory (M-MA009)
Recipient: Order No.: G18108644
Paul.Haydon Report Dated: 08/06/2018
150 Bershire Trail Submitter: Paul Haydon
W Barnstable, MA 02668' Description: rtn+voc
Laboratory ID#: 18108644-01 Matrix: Water-Drinking Water
Sample#: Sampled: 07/25/2018 10:20 By: Paul
Collection Addr: 150 Berkshire Trail,W Barnstable Received: 07/25/2018 15:40 By: Thiago
Sample Location- Turn Around: Standard
Analyst: yn Method: EPA 524.2 Dilution 1. Date Analyzed: 07/30/2018 @ 15:17
EPA 524.2- Volatile Organics by GC/MS
Result MCL MDL Result MCL MQL
Parameter ug/L ug/L ug/L Parameter ug/L ug/L ug/4
Dichlorodifluoromethane ND 0.50 Chloroethane ND 0.50
Chloromethane ND 0150 Chloroform 0.82 80 0.50
Vinyl chloride• ND 2.0 0.50 cis-1,2-Dichloroethene ND 70 0.50
Bromome thane ND 0.50 cis-1,3-Dichloropropene ND 0,50
1,1,1,2 Tetrachloroethane ND 0.50 Dibromochloromethane ND 0.50
1,1,1-Trichloroethane ND 200 0.50 Dibromomethane ND 0.50
1,1,2,2 Tetrachloroethane ND 0.50 Ethlbenzene. ND 700 0.50
1,1,2-Trichloroethane ND 5.0 0.50 Hexachtorobutadiene. ND 0.50
1,1-Dichloroethane ND 0.50 Fsopropylbenzene ND 0,50
1,1-Dichloroethene ND 7.0 0.50 Methylene chloride - ND 5.0 0.50
1,1-Dichloropropene ND 0.50 Methyt-tert-butyl ether ND 0.50:.
1,2,3 Trichlorobenzene ND 0.50 Naphthalene ND 0.50
i,2,3 Trichloropropane ND 0.50 n-Butylbenzene ND 0.50
1,2,4-Trichlorobenzene ND 70 0,50 n-Propylbenzene ND 0.50
1,2,4 Trimetnylbenzene ND 0.50 p Isopropyltoluene ND 0.50
1,2-Dibromo-3-chloropropane ND 0.50 sec-Butylbenzene ND 0.50.
1,2-Dibromoethane(EDB) ND 0.50 Styrene ND 100 0.50
1,2-Dichlorobenzene ND 600 0.50- tert-Butylbenzene ND 0150
1,2-Dichloroethane ND 5.0 0.50 Tetrachloroethene ND 510 0.50
1,2-Dichloropropane. ND. 0.50 Toluene ND 1000 0.50
1,3,5-Trimethylbenzene ND. 0.50 Total xylenes ND 10000 0.50
1,3-Dichlorobenzene ND 0.50 trans-1,2-Dichloroethene ND 100 0.50
1,3-Dichloropropane ND 0.50 trans-1,3-Dichloropropene ND 0:50
1,4-Dichlorobenzene ND 5.0 0.50 Trichloroethene ND 5.0 0150
2,2-Dichloropropene ND 0.50 Tdchlorofluoromethane ND o.50
2-Chlorotoluene ND 0.50 Compound Y.Recovered QC limits(%)
4-Chlorototuene ND 0.50 1,2-Dichlorobenzene•d4 126% 70 130
Benzene ND 5.0 0.50 p-Bromofluorobenzene 102%. 70 130
Bromobenzene ND 0.50
Bromochloromethane ND 0.50
Bromodichloromethane ND 0.50
Bromoforin ND 0.50
Carbon tetrachloride ND 5.0 0150
Chlorobenzene ND 100 0,50
ApprovedBy
Attached.please find the laboratory certified parameter list. r _
(Lab Director}
_ N PLOT PLAN
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CERTIFICATE OF ANALYSIS Page: 1
Barnstable County Health Laboratory
Report Dated: 02/17/2006
Report Prepared For:
Order No.: G0634437
Richard Hay don �
150 BerAireA-o d l lea' I^ (C) V
W Barnstable, MA 02668 �,(C
Laboratory ID#:1 0634437-01 Description: Water-Drinking Water
Sample#: 34437 Sampling Location 150 Berkshire Tr.West Barnstable,MA Collected: 02/01/2006
Collected by: R.Haydon
Received: 02/01/2006
Test Parameters
ITEM RESULT UNITS RL MCL Method# Tested
LAB: Organics
Oil& Grease BRL mg/L 5.0 SM 5520 B 02/10/2006
Routine
ITEM RESULT UNITS RL MCL Method# -jested'
LAB: Inorganics , �
Nitrate as Nitrogen 0.86 mg/L 0.10 10 EPA 300.0 o 1/zoos
LAB: Metals
Copper 0.23 mg/L 0.10 1.3 SM 311113 02 43/2006
Iron BRL mg/L 0.10 0.3 SM 311113 02/W2006
.Sodium 17 mg/L 1.0 20 SM 311113 02/03/2006
-LAB: Microbiology
Total Coliform Absent P/A o 0 309 02/01/2006
LAB: Physical Chemistry
Conductance 190 umohs/cm 2.0 EPA 120.1 02/01/2006
PH 6.3 pH-units 0 EPA 150.1 02/01/2006
Water sample meets the recommended limits for drinking water of all the above tested parameters.
Approved By:
(La Director)
a � 9 4 • q#\V$Fy
RL = Reporting Limit
MCL=Maximum Contaminant Level
Superior Court House, PO.Box 427, Barnstable, MA 02630 Ph: 508-375-6605
' 1
TOF %-' Ie-
ABLELOCATION G® � SEWAGE # 9,1-S
VILLAGE ZIL . Q!!I, ASSESSOR'S MAP & LOT '-D wv
iANSTALLER'S NAME & PHONE NO. &�YlJc37-
;EPTIC TANK CAPACITY , I -Y�'/�it1.�
''BLEACHING FACILITY:(type) �/J (size) xI�
O. OF BEDROOMS 13 PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER /2/ ?`4.5AJ
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED: 7
VARIANCE GRANTED: Yes No
I
i
a
J
No.. ....._.... F.Rx 04.......
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OE .HEALTH
TOWN OF BARNSTABLE
Appliration for Diijiuial Vorkg Tonotrnrtinn ramit
Application is hereby made for a Permit to Construct (,Y) or Repair ( ) an Individual Sewage Disposal
lo�
ystem OP1 _.. 1 1.v.. ar...... � .........................................
......
'on- ddre-s or t No.
................................ ......7._-���.........................................
Owner s-Addr
a -•----•.............................•--•-------.......••---............_.............-----......._ 7_ ..._..... T> /.. ...
......................
Installer Address
d Type of Building Size Lot............................Sq. feet
V g— �ye� _ _Expansion Attic ( ) Garbage Grinder ( )
Dwelling No. of Bedrooms.....................E.___..__..._....
aOther—Type of Building ......1P6._5........... No. of persons...._....--------------- Showers ( ) — Cafeteria ( )
dOther fixtures ------------------------------------------------------------•----------------------............----------------------•-----...---------...............
W Design Flow............ . ._..gallons per person per da Total dail flow____-__--___21.0...
g � --------------------- g P P P o0 Y..__. � � .................gallons.
WSeptic Tank—Liquid capacity.,/-f�l7(`1.gallons Length__=8_.....-_-= Width..,.)___..... Diameter________________ Depth................
xDisposal Trench—No. .................... Width.............._._...Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No......./.......... Diameter____ZY._ ------- Depth below inlet.._.._........... Total leaching area....1.YO...sq. ft.
Z Other Distribution box ( Dosing tank ( )
'-' Percolation Test Results Performed by........................ �, Date....^��� ��
W --- - ------
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water------------------------
f=, Test Pit No. 2......a_-_..minutes per inch Depth of.Test Pit--- ...._.... Depth to ground water-----/0 .�.
-------------------------------------------------------------------------------- .-----------............................................................
O Description of Soil---••-C!L61�_------5'1 mo..........IOIW4-------- Lt�............-........................................................
x
V ...............-•-------------------------••---------------------------------•••-•••------------------------•---•----------••---------•------•------------••-•-------•--•-••-------------•-------------.
W
-------------------------------------------------------------------------------------------------•------•--•-----------------------••----------••--------------•----------•••--•----------------•-------
Z. 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 TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
Fi ealth.system in operation until a Certificate of Compliance ha e issu d t
i ` �- /
Signed JC- ----------------- m.
e Dare
Application Approved By ....... ---------- B............
------ --- - -- - .. .... --------------------- ---......---- ——
.-...------ - -
Dace
Application Disapproved for the following reaso - ----- --------------------------------- ---------- -- --- ---------------------------- -- -------------------------------
.. .......................... . ..... ..----...---------- -- .... . ------------....-- - .--.......................................
----......----------..................
Permit No. TJ .. �./.-- ....--. -------- -Issued -- ------ --....................D-a.e
Dace
No.. ..._....... ......
-- i
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
,ppfiration for llhip vml Works Tofulrurtiott rjerutit
Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal
System
,ste o• a
9
._i ...aq....... � ----------
--------------------•--------............
Lat ddress
_ °< , ................................ % .........................................
OwnerAddress
�W ---•-•----_•_________________••--_.........-•-•....._--......................--••-••---•-•-- ..-- ��---SST_. fit(!ST , G = _!' i
�. ......................
Installer Address
Type of Building Size Lot............................Sq. feet
U "
Dwelling—No. of Bedrooms........17%,e .................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ---- -a406'5---------- No. of persons....._._C�_______________ Showers ( ) — Cafeteria ( )
dOther fixtures ..-•--•=••-•--•-••---------•-----------•--•----••--•--...---•--------••--•----•----•.... ............................................................
Design Flow.............57S'_!).....................gallons per person per day. Total dail flow__-_--_-.-_2-1.0.............._..gallons.
WSeptic Tank—Liquid capacity__/gallons Length--- Width.__......_ Diameter................ Depth................
x Disposal Trench—No..................... Width.............._..... Total Length.................... Total leaching area....................sq. ft..-
Seepage Pit No-------/.......... Diameter----- ob 1....... Depth below inlet...... ........... Total leaching area.....:3.VZ2...sq. ft.
Z Other Distribution box Dosing tank ( )
'-' Percolation Test Results Performed by______________________ '1Y c/ . ....O Ms,Date.... '-...9-1......
a
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water--___-_____-_-_-.--_-__.
GLI Test Pit No. 2......0?-------minutes per inch Depth of Test Pit....ZY--------- Depth to ground water.....
9 -----------•-----------------•-•--...-•---_••------------_--------••-----_--___---•-•.....-----_._--.........................................................
O Description of Soil-------- L i i4/ S14-1v_ ......... "------.5/477------------------------------------------•-•---•--•------------•---
W
U .-------------•----•-----_-•---_-••-•---------------••-•--•-•---.....-••-----------_--_-----....------_--•------•---_----_-------•--•---•-•-------------------•---......................................
W
x ---------------------------------------------------------------------------------------------------•---------------------------------------------------------------------------•--.....---------•-------
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 TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance has,,ee issu th rboa d heeaaltth
Signed..... - --- --- --------`--...------ m; 'r.::= _ , ... - /--- - -------------------
.; C Dare
Application Approved By "". _"_ ✓� � _B---------
--- .-- .
Dace
Application Disapproved for the following reason - ------------- -- -------- - --------------------------------- -------------------------------------------------------------
----- ------------ """"."._" ...."_""----..""._."""__."............"...........----------*------------------ Dace_-""_. .........-------_"ace
_,_e.-------.........
D
Permit No. "_.:... Issued .
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Ce>rtifira#e of Comlatiance
THIS IS TO CERTIFY, That the Individual Sewage Disposal Systern constructed ( X ) or Repaired ( )
by 60'J's/ / `
.."-----------------------------------------------------------------------------------------------------
[rC// _""��Install,yam /`' . �/`G,J1—� "v `
at "-- ----------------- -- -----------------................- ..................... -,(vim- _..."_ ----L. -----..._..----- --- - ---...- .........
has been installed in accordance with the provisions of TITLE 5� he �j'ronmental Cq�e s,� i in
the application for Disposal Works Construction Permit No. �T_r..,5. dated / w"�- ....--- ---
` THE ISSUANCE H I I ATE HALL NOT BE CON TR ED T H
OF IS CER� F C S O S U SAS A GUARA�TEE TH
SYSTEM WILL FUNCTION SATISFACTORY. f/
DATE--------------------------------------------------------- f� V. `.'..... Inspector ............--- ------ -- ----:................
1
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
No.. .............. FEE..................--•---
�i��r�a��,1 � � �� ��rtuan rruti�
Permission is/hereby granted------. - �.. =------------------•-•-------------- ........
to Constr ct ( epair�( ) anIndivldua Sewage Disposal System
f
.
Street �
as shown on the application for isposal Works Construction Pent No.___ _____ ed..�p� __ v \l.c^ ...
-- --------. ;....
Board of ealth,
DATE---------------- . ..... ....._._.... ...............
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FORM 36508 HOBBS Q WARREN.INC..PUBLISHERS
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FAX NO, (5U8) 240-1215
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No.--- ---- -j-----71 Fee---------------------
BOARD OF HEALTH
TOWN OF BARNSTABLE
�, licat ion Ar V ell �Com9truct ion vermit
cC 1
App 'c tion is here y made for a permit to Construct ( ), Alter ( ), or Repair ( )an individual Well at:
----------------
Location s Assessors Map and Parcel
--------------------------------------------------------------------------------------------------
OwnePrileler
�jf� Address
1 - - -- C --- ----------------------------------------------------------- -------- -----------
------------ --
Installer — Address
Type of Building FgAnn
Dwellin4u0z = ---------------------------
Other - Type of Building ------- No. of
! - -----
Persons---------------------------------------------___-___----
Type of Well RvL - ----------- 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 -- - - —- -
dJa�'
Application Approved By------ /;d
at
Application Disapproved for the following reasons:-----------------------_________________________________________________________----------------------
-------------------------------- - ----- -- ---------------------------------------------------------------- - -------- ----------------
date
Permit No.---- -
------ ---�----------------------------------------------- Issued----=----------------� date-�-- --- -�--- -- -------------------------- ---
BOARD OF HEALTH
TOWN OF BARNSTABLE
(Certificate ®f tom ianrr
THIS S TO CERTIFY, That the Individual Wel Constructed ( Altered ( ), or Repaired ( )
�j Installer
---'------ ----- ----- I g'(A5�1f -- -------
has been installed in accordance with the provisions of the Town of Barnstable ar of Hea7lt Private Well Pr ction
Regulation as described in the application for Well Construction Permit No. Dated---------------------------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL
SYSTEM WILL FUNCTION SATISFACTORY.
DATE----------------------------------------------------------------------------------- Inspector—------------------------------------------------------------------------------
L
�•' -ram C �� � }� �..
No.-------------------, Fee- ---
BOARD OF HEALTH
TOWN OF BARNSTABLE ry
. by lication Ar Vell Con5truct ion Permit
ti Applic tion is hereby made°for a permit to Cdnstruct ( ), Alter ( ), or Repair ( )an individual Well at:
� c isli �2r- it - ------------ ------- ------------------------------
i ---------------------------- P
---
Location — A dr s P Assessors Ma and Parcel
40' CA
--------------------
------------------------
----
-----
-------
-----------------------
------------
.—------------------
Owner /jf� -Address —
...
11 ---------- / — -----------------------------------
Installer — Driller Address
Type of Building
Dwelling ----------------------------
Other - Type of Building----------------------------------- No. of Persons---------------------------------------------------------
i/ s�V C
Type of Well- J =------------------------------------- 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'' f
Signe - / r��l �- - � -- -- ---------[-7/-,Ta-
,dApplication Approved By------r------ --"r� -----� =-= �- '`-- ___�1_ ___7�_____te,
Application Disapproved for the following reasons:--___________—----------_---------____________________—____________________ ,
-------------------------------s------------- -- ------
I 1 ---� date------- ------
Permit No.-_!�- -- --- - - - Issued--------- - -#--- - - - - -
C date
fi
BOARD .OF HEALTH
TOWN OF BARNSTABLE
Certificate ®f Com Hance
THIS S//T. O CERTIFY, That the Individual WelkConstructed ( , Altered ( ), or Repaired ( )
------------------------- -----------------------------------------------------
— Installer
a - � --G - ?p Qr>r '; - 5`�=- i,���isti ---'71?A k--- -------
has been installed in accordance with the provisions of the Town of Barnstable�ba/r of Health Private Well Pr�.ection
Regulation as described in the application for Well Construction Permit No.,,)11?�_-,I T_--Dated---------------------------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL
SYSTEM WILL FUNCTION SATISFACTORY.
DATE-------------------------------- ---- -------- --- Inspector---------------------------------------------------------------------------
BOARD OF HEALTH
TOWN OF BARNSTABLE
well �on�truction�erYrtit ,,,.
NO.
-j � Fee---—---------
Permission is hereby grante - --`--r"X_Ii M---- -__a,4/ -`- -__^'- }-
to Construct (�, Alter ( ), or Repair ( ) an Individual Well a '� �j�,/��A ��� ��
No. ---------------------------------------------------------------------------------------------- !Ci
--------------------------------------------------------- ---------- ----- -------------
Street �j
as shown on hMfi ation f r a Well Construction Permitf-- -No.-------- � -----�--�---------------- ------------ Date J j-----�-=�-r---------;— �--
Board of Health
DATE - - "- - -r
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JRyil �..l.iT Itl: ,.T1:.,:,::1.., L .1,
ENVIROTECH LABORATORIES
-_ Mass. Cert. #:MA063 _
449 Route 130 Sandwich,MA 02563 (508) 888-6460 =_
CLIENT: Rick Hayden LOCATION: Lot 29 Berkshire Trails
�.. ADDRESS: 1� . Barnstable, MA
- -
COLLEC T ED BY: �-`Tile SAMPLE DATE: 11-18-91 TIME
DATE RECEIVED:11-18-91 SAMPLE ID: Z429
New Well WELL DEPTH: . 144/180r 20 gal/min
JOB — .
- RESULTS OF ANALYSIS: Hi
Parameter Units Recommended limit Result -
Coliform bacteria;'100 m! (MF Method) 0 0 -
pH pH units 6.0-8.5 6.87 —
Conductance umhos/cm 500 76
Sodium mg/L 20.0 8.4
Nitrate-N mg/L 10.0 <0.03 -�
Iron mg/L 0.3 0.08
>^ Manganese mg/L 0.05
0.03
Hardness mg/L as CaCO 3 500
E` 10.4
Sulfate mg/L 250
3.5
Potassium mg/L 20.0
0.7 -
Alkalinity mg/L 200 -
7.6
_ � I
. Chloride mg/L 250
15.8
Turbidity NTU 5•0 5.4 .
€' Color APC units 15.0 -3
�0
4 Background bacteria
1� ;COMMENT
EPA Method .601/602 y0C ug/L' Below;.Reporting Limits
� 4
c '^ .See Attached Report
` YES No WATER IS SUITABLE.FOR DRINKING PURPOSES FOR PARAMETERS TESTED.
:X a l l
DATE --
-
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GROUNDWATER
ANALYTICAL
EPA METHODS 601 and 602
Volatile Organics (GC/PIO/ELCD)
Field ID: Z429 Lab ID: 2262-01
Project: Rick Hayden�Z429 QC Batch: VGA-885
Client: Envirotech abs Sampled: 11-18-91
Cont/Prsv: 40ml VOA Vial/NaHSO4 Cool Received: 11-19-91
Matrix: Aqueous Analyzed: 11-21-91
PARAMETER CONCENTRATION REPORTING LIMIT
(ug/L) (ug/L)
Dichlorodifluoromethane BRL 5.
Chloromethane BRL 1
Vinyl Chloride BRL 1
Bromome.thane BRL 5
Chloroethane BRL 1
Trichlorofluoromethane BRL 1
1,1-Dichloroethene BRL 1
Methylene Chloride BRL 1
trans-1,2'-Dichloroethene BRL 1
1,1-Dichloroethane BRL 1
cis-1,2-Dichloroethene * BRL 1
Chloroform BRL 1
1, 1, 1-Trichloroethane BRL 1
Carbon Tetrachloride BRL 1
Benzene BRL 1
1,2-Dichloroethane BRL 1
Trichloroethene BRL 1
1,2-Dichloropropene BRL 1
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 1
m+pp-Xylene * BRL 1
oly-1 ene * BRL 1
Bromoform BRL 1
1,1,2,2-Tetrachloroethane BRL 1
1,3-Dichlorobenzene BRL 1
,.1,47Dichlorobenzene BRL 1
1,2-Dichlorobenzene BRL 1
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
tk Reporting Limit. Method References: Method 601 - Purgeable Halocarbons and Method 602 - Purgeable
Aromatics; 40 C.F.R. 136, Appendix A (1986).