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Home My WebLink About0030 BOXWOOD DRIVE - Health 30 BOXWOOD DR., W.BARNSTABLE A= CERTIFICATE OF ANALYSIS Page: 1 Q �1 Barnstable County Health Laboratory �ss!cHui Report Prepared For: Report Dated: 5/7/2008 Shaun F. Harrington All Cape Well Drilling Order No.: G0846058 P O Box 126 Brewster, MA 02631 Laboratory ID#: 0846058-01 Description: Water-Drinking Water Sample#: Sampling Location 30 Boxwood,W:Barnstable;MA Collected: 5/6/2008 Collected by: MLH �� Received: 5/6/2008 Routine +Ammonia ITEM RESULT UNITS RL MCL Method# Tested Ammonia ND mg/L 0.20 EPA 350.1 M 5/6/2008 Nitrate as Nitr^tren 2..3 mg/L 0.10 t_n Fpp,7.00.0 5/6/2nng Copper ND mg/L 0.10 1.3 SM 3111 B 5/7/2008 Iron ND mg/L 0.10 0.3 SM 3111B 5/7/2008 Sodium 24 mg/L 1.0 20 SM 3111 B 5/7/2008 Total Coliform Absent P/A 0 0 SM9223 5/6/2008 Conductance 240 umohs/cm 2.0 EPA 120.1 5/6/2008 pH 6.7 pH-units 0 SM 4500 H-B 5/6/2008 Sodium_level is above the maximum contaminahi'level. Those on a low sodium"diet n:ay-wish to consull a physician. v~ Approved By• _ ----_ — (La irector) /7 �a ND=None Detected RL = Reporting Limit MCL=Maximum.Contaminant Level Superior Court House, PO. Box 427, Barnstable, MA 02630 Ph: 508-375-6605 CERTIFICATE OF ANALYSIS Page: 1 j p n` Yi Barnstable County Health Laboratory �y�s�cHus" Report Prepared For: Report Dated: 5/7/2008 Shaun F. Harrington All Cape Well Drilling Order No.: G0846058 P O Box 126 Brewster, MA 02631 Laboratory ID#: 0846058-01 Description: Water-Drinking Water Sample#: Sampling Location 30 Boxwood,W.Barnstable,MA Collected: 5/6/2008 Collected by: MLH Received: 5/6/2008 EPA 524.2 - Volatile Organics by GUMS ITEM RESULT UNITS RL MCL Method# Analyst Tested Note Dichlorodifluoromethane ND ug/L 0.50 EPA 524.2 yn . 5/6/2008 O'Norome.tha_ne ND. 0.50 rn,q c2n^ 5/F/ 008: Vinyl chloride ND ueL 0.50 2.0 EPA 524.2 yn 5/6/2008 Bromomethane ND ug/L 0.50 EPA 524.2 yn 5/6/2008 1,1,1,2-Tetrachloroethane ND ug/L 0.50 EPA 524.2 yn 5/6/2008 1,1,1-Trichloroethane ND ug/L 0.50 200 EPA 524.2 yn 5/6/2008 1,1,2,2-Tetrachl oro ethane ND ug/L 0.50 EPA 524.2 yn 5/6/2008 1,1,2-Trichloroethane ND ug/L 0.50 5.0 EPA 524.2 yn 516/2008 1,1-Dichloroethane ND ug/L 0.50 EPA 524.2 yn 516/2008 ],I-Dichloroethane ND ug/L 0.50 7.0 EPA 524.2 yn 5/6/2008 1,1-Dichloropropene. ND ug/L 0.50 EPA 524.2 yn 5/6/2008 1,2,3-Trichlorobenzene ND ug/L 0.50 EPA 524.2 yn 5/6/2008 1,2,3-Trichloropropane ND ug/L 0.50 EPA 524,2 yn, 5/6/2008 1,2,4-Trichlorobenzene ND ug/L 0.50 70 EPA 524.2 yn 5/6/2008 1,2,4-Trimethylbenzene ND ug/L 0.50 EPA 524.2 yn 5/6/2008 1,2-Dibromo-3-chloropropane ND ug/L 0.50 EPA 524.2 yn 5/6/2008 1,2-Dibromoethane(EDB) ND ug/L 0.50 EPA 524.2 yn 5/6/2008 1,2-Dichlorobenzene ND ug/L 0.50 660 EPA 524.2 yn 5/6/2008 1,2-Dichloroethane ND ug/L 0.50 5.0 EPA 524.2 yn 5/6/2008 112-Dich.lorop op- e. D ug"L a.50 CYt>524.2 yn 5/5/2008 1,3,5-Trimethylbenzene ND ug/L 0.50 EPA 524.2 yn 5/6/2008 1,3-Dichlorobenzene ND ug/L 0.50 EPA 524.2 yn 5/6/2008 1,3-Dichloropronane ND ug/L 0.50 EPA 524.2 yn 5/6/2008 1,4-Dichlorobenzene ND ug/L 0.50 5.0 EPA 524.2 yn 5/6/2008 2,2-Dichloropropane ND ug/L 0.50 EPA 524.2 yn 5/6/2008 2-Chlorotoluene ND ug/L 0.50 EPA 524.2 yn 5/6/2008 4-Chloroto were ND ug,/L 0.50 EPA 524.2 yn 5/6/2008 Benzene ND ug/L 0.50 5.0 EPA 524.2 vn 5/6/2008 Brornobenzene ND ug/L 0.50 EPA 524.2 yn 5/6/2008 Brornochlorornethdne ND ug/L 0.50 EPA 524.2 yn 5/6/2008 Bromodichloromethane ND Ug/1 0.50 EPA 524.2 yn 5/6/2008 Brcmo.orm ND ug/L 0.50 EPA 524.2 yn 5/6/2008 ND=None Detected RL = Reporting Limit MCL=Maximum Contaminant Level Superior Court House, PO. Box 427, Barnstable, MA 02630 Ph: 508-375-6605 66!�� ` "� CERTIFICATE OF ANALYSIS Page: 2 y{ Barnstable County Health Laboratory \ysstMyt%" Report Prepared For: Report Dated: 5/7/2008 Shaun F.Harrington All Cape Well Drilling Order No.: G0846058 P O Box 126 Brewster, MA 02631 Laboratory ID#: 0846058-01 Description: Water-Drinking Water Sample#: Sampling Location 30 Boxwood,W.Barnstable,MA Collected: 5/6/2008 Collected by: MLH Received: 5/6/2008 EPA 524.2- Volatile Organics by GUMS ITEM RESULT UNITS RL MCL Method# Analyst Tested Note Carbon tetrachloride ND ug/L 0.50 5.0 EPA 524.2 yn 5/6/2008 Chlorobenzene ND -,g/L 0.50 100 r-nA 524.2 n 5;g!2008 Chloroethane ND ug/L 0.50 EPA 524.2 yn 5/6/2008 Chloroform ND ug/L 0.50 80 EPA 524.2 yn 5/6/2008 cis-1,2-Dichloroethene ND ug/L 0.50 70 EPA 524.2 yn 5/6/2008 cis-1,3-Dichloropropene ND ug/L 0.50 EPA 524.2 yn 5/6/2008 Dibromochloromethane ND ug/L 0.50 EPA 524.2 yn 5/6/2008 Dibromomethane ND ug/L 0.50 EPA 524.2 yn 5/6/2008 Ethylbenzene ND ug/L 0.50 700 EPA 524.2 yn 5/6/2008 Hexachlorobutadiene ND ug/L 0.50 EPA 524.2 yn 5/6/2008 Isopropylbenzene ND ug/L 0.50 EPA 524.2 yn 5/6/2008 Methylene chloride ND ug/L 0.50 5.0 EPA 524.2 yn 5/6/2008 Methyl-tert-butyl ether 1.1 ug/L 0.50 EPA 524.2 yn 5/6/2008 Naphthalene ND ug/L 0.50 EPA 524.2 yn 5/6/2008 n-Butylbenzene ND ug/L 0.50 EPA 524.2 yn 5/6/2008 n-Propylbenzene ND ug/L 0.50 EPA 524.2 yn 5/6/2008 p-Isopropyltoluene ND ug/L 0.50 EPA 524.2 yn 5/6/2008 sec-Butylbenzene ND ug/L 0.50 EPA 524.2 yn 5/6/2008 Styrene ND ug/L, 0.50 100 EPA 524.2 yn 5/6/2008 tert-Butylbenzerw ND ug,:-," 0.50 EP f,524.2 yn 5i6/2003 Tetrachloroethene ND ug/L 0.50 5.0 EPA 524.2 yn 5/6/2008 Toluene ND ug/L 0.50 1000 EPA 524.2 yn 5/6/2008 Total xylenes ND ug/L 0.50 10000 EPA 524.2 yn 5/6/2008 trans-1,2-Dichloroethene ND ug/L 0.50 100 EPA 524.2 yn 5/6/2008 trans-1,3-Dichloropropene ND ug/L 0.50 EPA 524.2 yn 5/6/2008 Trichloroethene ND ug/L 0.50 5.0 EPA 524.2 yn 5/6/2008 Trichlorofluoromethane ND ug/L 0.50 EPA 524.2 yn 5/6/2008 Sodium level is above the maximum contaminant level. Those on a low sodium diet may wish to consult aphysician. 1 Approved By: (Lab ector)i � -7 ND=None Detected RL = Reporting Limit MCL=Maximum Contaminant Level Superior Court House, PO. Box 427, Barnstable, MA 02630 Ph: 508-375-6605 BOARD OF OF HEALTH TOWN OF BARNSTABLE __ �v �o b� �ppiication,for�eCi �on�truct ion hermit A lication is hereby made for a,permit to Construct Z), Alter ( ), or Repair ( )an individual Well at: -P -- o_0 -_-- Location — Address Assessors Map and Parcel Owner Address Installer — It�ri er Address Type of Bui ing weling----—----------------------------------------------------- er - Type of Building----------------------------- No. of Persons------------------------------ --------- Type of Well- ---- �� V ---— -- - Capacity--- ---- - --— — Purpose of Well----�� '�.�7 —— - 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 rtif' at . omplia a has been issued by the Board of Health. gne -- -- --- — — -- -�(-' ��---- Application Approved - -----------------------------_--_-- S � ate ----------------------- dace Application Disapproved for the following reasons:------------------------------------__________________—________ ---------------------—------------------------------------------------------------------------------------ ---- - -- ----- — --- - - -------------- - -- -- ------- date Permit No. -- ` — -- - Issued--� --- `-' -------------- ----------------- date BOARD OF HEALTH TOWN OF BARNSTABLE Certificate Of Compliance THIS IS TO CERTIFY, That the Individual Well 4nstructed ( ), Altered ( ), or Rep iced ( ) Y- -- -— -- --------------- Installer ------------------- at- — � -- Lt��C�Q _�--� --_b YZr 1 p-------- - -- - - -has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well P otegtion �`�ated-��- �_`0 Regulation as described in the application for Well Construction Permit No. - - ------- -- --- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE--------- —_fir __ Inspector - ----- -- - --------- i No. rJ__C_ 5_ Fee------------------- BOARD OF HEALTH TOWN OF BARNSTABLE App[icat ion ArWell Congtruct ion Permit Application is hereby made for ermit to Construct ( ), Alter ( ), or Repair ( )an individual Well at: PP P Location — Address Assessors Map and Parcel _ Owner Address II Installer — Dril r _ Address Type of Building welling ---------------------------------------------------- Other - T e of Building ------------------- No. of Persons----------------------------------------__-__- Capacity n V Type of Well------------1--�---P v-C'-=--------------- P Y------- �-�-"-'c;-- --------------------- -- 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 rtifi ate . f'� omplian a has been issued by the Board of Health. i f gne =C E'-�4-��-- 1 •ate i Application Approved -------------------_—__—_____-- /-- ----- Gate -- -------- Application Disapproved for the following reasons:----------------------------------_____-________________—___—___—_________ - ------- ---- - - ------- date ---------------- -- --------- ' W � ^�l — - -- Issued----= - �J --------— — Permit No. -------------------------- - - - ----------------- date BOARD OF HEALTH TOWN OF BARNSTABLE Certificate ®f Compliance I THIS IS TO CERTIFY, That the Individual Well nstructed ( ), Altered ( ), or Repaired'( ) bY------------ � -V- - - ------------------------- - —- Installer �._. at- — -- _ �1�. �_ `- -- ±� -r�i�� -- ------------------------------------- has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protec ion Regulation as described in the application for Well Construction Permit No. 1-6 Y&ed---5 THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATEInspector------------------------------------------------------------------------- ------------------L--- ------------------I-------- ------------------------------- — -------------_— BOARD OF HEALTH TOWN OF BARNSTABLE Well Congtruct ion Permit No. —l'--=` Fee-- -------- Permission is he eby granted- -EAU-L- _� E_' b L�--------------------------------------------—- - to Construct ( Alter ( ), or Repair ( ) an Individual Well at: No. - — --- -------------------------------------------------------------------------------------------- Street ` as shown on the application for a Well Construction Permit / 9� No. - - — - — -- - -- -- - axed--— - / - -d' ---- -------------- 4 - Board of Health DATE---J---6 --�� - -- i Page: 1 0 CERTIFICATE OF ANALYSIS v ni `ysr�cH�ct��' Barnstable County Health Laboratory Report Dated: 10/12/2006 Report Prepared For: Joshua E. Roberts Order No.: G0638457 Roberts Septic 88 Huckleberry Ln. Marstons Mills, MA 02648 Laboratory ID#: 0638457-01 Description: Watcr.�•Driuk�g Water Sample#: Sampling Loca-fibn�30 Boxwood Dr.West Barnstablel-NIA'_ Collected: 10/11/2006 Collected by: Customer Received: 10/11/2006 Routine ITEM RESULT UNITS RL MCL Method# Tested LAB: Inorganics Nitrate as Nitrogen 3.3 mg/L 0.10 10 EPA 300.0 10/11/2006 LAB: Metals Copper 0.14 mg/L 0.10 1.3 SM3111B 10/12/2006 Iron BRL mg/L 0.10 0.3 SM 3111 B 10/12/2006 Sodium 37 mg/L 1.0 20 SM 3111B 10/12/2006 LAB: Microbiology Total Coliform Absent P/A 0 0 SM9223 10/11/2006 LAB: Physical Chemistry Conductance 180 umohs/cm 2.0 EPA 120.1 10/11/2006 pH 6.3 pH-units 0 EPA 150.1 10/11/2006 Sodium level is above the maximum contaminant level. Those on a low sodium diet may wish to consult a ph siian. Approved By: (L4b recto _ C./Y 01 i RL = Reporting Limit MCL=Maximum Contaminant Level Superior Court House, PO. Box 427, Barnstable, MA 02630 Ph: 508-375-6605 • 8 COMMONWEALTH OF MASACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAI AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET BOSTON MA 02108(617)292-3500 TRUDY COXE Secretary ARGEO PAULCELLUCCI DAVID B.STRUHS Govemor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 30 BOXWOOD DR.WEST BARNSTABLE, MA 02668 Name of Owner RUSS PRICE Address of Owner: 30 BOXWOOD DR.WEST BARNSTABLE,MA 02668 4 Date of Inspection: 3/27/00 ( � ! Name of Inspector: JOHN GRACI _. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) o APR 5 2000 Company Name: SEPTIC INSPECTIONS \'. TOWN OF _j Mailing Address: P.O.BOX 2119 TEATICKET,MA.02536 � ► t::r_;rr Telephone Number: 608-564-6813 FAX 608-664-7270 v 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 Further Evaluat• n By the Local Approving Authority Fails Inspector's Signature: Date:3/28/00 The System Inspector shall sub t 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 "The inspection is based on criteria defined in Title V code 310 CMR 15.303.My findings are of how the system is performing at the time of inspection.My inspection does not imply any warranty or guarantee of the longevity of the septic system and any of its component's useful life." THE SYSTEM PASSES TITLE V INPECTION.RECOMMEND PUMPING THE SYSTEM NOW AND MAINTAINED EVERY TWO YEARS. revised 912/98 Page 1 of 11 • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 30 BOXWOOD DR. WEST BARNSTABLE, MA 02668 Name of Owner RUSS PRICE Date of Inspection: 3/27/00 INSPECTION SUMMARY: Check A, B, C, or D: A. SYSTEM PASSES: X I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist.Any failure criteria not evaluated are indicated below. 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. Indicate yes,no,or not determined(Y,N,or ND).Describe basis of determination in all instances.If"not determined",explain why not. nLa 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 failure is imminent.The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. nta 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 pass inspection if(with approval of the Board of Health). _broken pipe(s)are replaced _obstruction is removed _distribution box is levelled or replaced nta 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 revised 9/2/98 Page 2 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 30 BOXWOOD DR.WEST BARNSTABLE, MA 02668 Name of Owner RUSS PRICE Date of Inspection: 3/27/00 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 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)THAT 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 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 I 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 is equal to or less than 5 ppm,Method used to determine distance nLa (approximation not valid). 3) OTHER n/a revised 9/2/98 Page 3 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 30 BOXWOOD DR. WEST BARNSTABLE, MA 02668 Name of Owner RUSS PRICE Date of Inspection: 3/27/00 D. SYSTEM FAILS: 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 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 an 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 Il. X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. X Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone I of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well, X Any portion of a cesspool or privy is less-than 100 feet but greater than 50 feet from a private water supply,well with no acceptable water quality analysis.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: 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: 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 _ X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply - X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.30412).Please consult the local regional office of the Department for further information. revised 9/2/98 Page 4 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 30 BOXWOOD DR.WEST BARNSTABLE, MA 02668 Name of Owner RUSS PRICE Date of Inspection: 3/27/00 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 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)THAT 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 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 is equal to or less than 5 ppm,Method used to determine distance Wa(approximation not valid). 3) OTHER n/a revised 9/2/98 Page 3 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 30 BOXWOOD DR.WEST BARNSTABLE, MA 02668 Name of Owner RUSS PRICE Date of Inspection: 3/27/00 D. SYSTEM FAILS: 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 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 an 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 Q. X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. X Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _ X Any portion of a cesspool or privy is within a Zone I of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well, X Any portion of a cesspool or privy is less-than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis.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: 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: 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 _ X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.30412).Please consult the local regional office of the Department for further information. revised 9/2/98 Page 4 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 30 BOXWOOD DR. WEST BARNSTABLE, MA 02668 Name of Owner: RUSS PRICE Date of Inspection: 3/27/00 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,excluding 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,For example,Plan at B4O,H, X _ Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable)1 5.302(3)(b)] X _ The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Subsurface Disposal Systems. a revised 9/2/98 Page 5 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 30 BOXWOOD DR.WEST BARNSTABLE, MA 02668 Name of Owner RUSS PRICE Date of Inspection: 3/27/00 FLOW CONDITIONS RESIDENTIAL: Design flow: 110 g.p.d./bedroom Number of bedrooms(design): 3 Number of bedrooms(actual): Total DESIGN flow: 330 gpd Number of current residents:2 Garbage grinder(yes or no):NO Laundry(separate system)(yes or no): NO If yes,separate inspection required Laundry system inspected(yes or no): NO Seasonal use(yes or no): NO Water meter readings,if available(last two year's usage): n/a gpd Sump Pump(yes or no): NO Last date of occupancy: n/a COMMERCIAL/INDUSTRIAL Type of establishment: n/a Design flow: n/a gpd(Based on 15.203) Basis of design flow:n/a Grease trap present:(yes or no): NO Industrial Waste Holding Tank present:(yes or no): NO Non-sanitary waste discharged to the Title 5 system:(yes or no):NO Water meter readings.if available: n/a Last date of occupancy:n/a OTHER: (Describe) n/a GENERAL INFORMATION PUMPING RECORDS and source of information: SYSTEM WAS LAST PUMPED IN 1995 System pumped as part of inspection:(yes or no):NO If yes,volume pumped n/a gallons Reason for pumping:n/a 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) _ I/A Technology etc.Attach copy of up to date operation and maintenance contract _ Tight Tank Copy of DEP Approval Other:n/a APPROXIMATE AGE of all components,date installed(if known)and source of information: ORIGINAL 1973 WITH A REPAIR IN 1985 Sewage odors detected when arriving at the site:(yes or no) NO revised 9/2/98 Page 6 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 30 BOXWOOD DR. WEST BARNSTABLE, MA 02668 Name of Owner RUSS PRICE Date of Inspection: 3127/00 BUILDING SEWER:X (Locate on site plan) Depth below grade: 18" Material of construction: _ cast iron X 40 Pvc _ other(explain) Distance from private water supply well or suction line: n/a Diameter: 4" Comments: (condition of joints,venting,evidence of leakage,etc.) THE WELL IS 100+FEET TO SYSTEM SEPTIC TANK: X (locate on site plan) Depth below grade: 12" Material of construction: X concrete_ metal_ Fiberglass_ Polyethylene_ other explain: n/a If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): NO Age: n/a Dimensions: 1000G L 8'6"H 6'7"W 4'10 Sludge depth: 2" Distance from top of sludge to bottom_of outlet tee or baffle: 32" Scum thickness: 2" 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: n/a How dimensions were determined: MEASURED 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.) THE SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND.RECOMMEND PUMPING NOW EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE. GREASE TRAP: _ (locate on site plan) Depth below grade: n/a Material of construction: _concrete_ metal_ Fiberglass _ Polyethylene_other Explain: n/a Dimensions:n/a Scum thickness: n/a Distance from top of scum to top of outlet tee or baffle: n/a Distance from bottom of scum to bottom of outlet tee or baffle n/a Date of last pumping: n/a Comments: (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.) n/a revised 9/2/98 Page 7 of 11 ' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 30 BOXWOOD DR.WEST BARNSTABLE, MA 02668 Name of Owner RUSS PRICE Date of Inspection: 3/27/00 TIGHT OR HOLDING TANK: _ (Tank must be pumped prior to,or at time of,inspection) (locate on site plan) Depth below grade: n/a Material of construction: _concrete_ metal_Fiberglass _Polyethylene _other Explain: n/a Dimensions: n/a Capacity: n/a gallons Design flow: n/a gallons/day Alarm present: NO Alarm level:N/A Alarm in working order:NO Date of previous pumping: n/a Comments: (condition of inlet tee,condition of alarm and float switches,etc.) n/a DISTRIBUTION BOX:X (locate on site plan) Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE ,Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) THE DISTRIBUTION BOX IS STRUCTURALLY SOUND,SYSTEM APPEARS TO BE FUNCTIONING PROPERLY,SYSTEM SHOWS NO SIGNS OF FAILURE. PUMP CHAMBER: _ (locate on site plan) Pumps in working order:(Yes or No): NO Alarms in working order(Yes or No): NO Comments: (note condition of pump chamber,condition of pumps and appurtenances.etc.) n/a revised 9/2/98 Page 8 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 30 BOXWOOD DR.WEST BARNSTABLE, MA 02668 Name of Owner RUSS PRICE Date of Inspection: 3/27/00 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods) If not located,explain: n/a Type: leaching pits,number:(1)1000 GAL 6'X 6' leaching chambers,number: (n/a)n/a leaching galleries,number: (n/a)n/a leaching trenches,number,length: (n/a)n/a leaching fields,number,dimensions: (1)LEACH FIELD overflow cesspool,number: (n/a)n/a Alternative system: n/a Name of Technology: n/a Comments: (note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) THE LEACH PIT IS STRUCTURALLY SOUND.THE LEACH FIELD IS FUNCTIONING PROPERLY.THE LEACH FIELD SHOWS NO SIGNS OF FAILURE. CESSPOOLS: _ (locate on site plan) Number and configuration: n/a Depth-top of liquid to inlet invert: n/a Depth of solids layer: n/a Depth of scum layer. n/a Dimensions of cesspool: n/a Materials of construction: n/a Indication of groundwater: n/a inflow(cesspool must be pumped as part of inspection)NO Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) n/a PRIVY: (locate on site plan) Materials of construction: n/a Dimensions: n/a Depth of solids: n/a Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) n/a f revised 9/2/98 Page 9 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 30 BOXWOOD DR. WEST BARNSTABLE, MA 02668 Name of Owner RUSS PRICE Date of Inspection: 3/27/00 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes into house) LA C - g 0 M a3 30 A-6 A RA 31 BC '3 CA 33 a33� cC 8 revised 9/2/98 Page 10 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 30 BOXWOOD DR. WEST BARNSTABLE, MA 02668 Name of Owner RUSS PRICE Date of Inspection: 3/27/00 NRCS Report name: n/a Soil Type: n/a Typical depth to groundwater: n/a USGS Date website visited: n/a Observation Wells checked: NO Groundwater depth: Shallow_ Moderate_ Deep_ SITE EXAM _ Slope _ Surface water _ Check Cellar Shallow wells Estimated Depth to Groundwater 10 Feet+ Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record _ Observed Site(Abutting property,observation hole,basement sump etc.) Determined from local conditions _ Checked with local Board of health Checked FEMA Maps _ Checked pumping records Checked local excavators,installers X Used USGS Data Describe how you established the High Groundwater Elevation.(Must be completed) USGS MAPS AND CHARTS-10+FEET revised 9/2/98 Page 11 of 11 TOWN 4��ABLE o L,C)CA'rION .0 SEWAGE # U3 e ®�. pl� VILLAGE S ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) �a0� NO. OF BEDROOMS BUILDER OR OWNERU� �� PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: , Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) / Feet Furnished by �eCIL o d.. C I AA�3 c (�31 PA)) � CA cN cep� LOCATION !- � SEWAGE PERMIT N0. Y I ,l L A G'E-- ASSESSORS MAP NO: r PARCEL NO: d u l - INST LL,ER-'S v` . AME i ADDRESS R OR OWNER" � DATE ' PERMIT ISSUED DATE COMPLIANCE ISSUED rk ;l� L t ' o N 0 G 7 7Fes$.... .. .... . THE COMMONWEALTH.OF MASSACHUSETTS BOAR® OF HEALTH . . ,r_.a ----------.................................... Appl r ation for Disposal Works Tonstrurtion 1hrutit Application is hereby made for a Permit to Construct ( ) or Repair (x) an Individual Sewage Disposal System at• 2 a 14 ocatioSj[Ejn-Add r t e AZ x ................................... Addres kj Installer Address Type of Building Size Lot............................Sq. feet U Dwelling.—No. of Bedrooms.........��................................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of persons..... .....`?______________ Showers — Cafeteria Other fixtures ------------- y. Total daily flow...................:........................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.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date.................................... ,.� Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ f� Test Pit No. 2................minutes per inch Depth of Test Pit...........:........ Depth to ground water-________---____---____- P4 ----------------------------•...._........-•---••...-•-••-----------------------•-.......----.....-•......................................................... 0 Description of Soil.......................................................................................................................................................................... x U ---.----••-•-------------------- ------------------------------ --------------------------------------------------------------•--------------------=---------------------.--------------- W -------------------•---••-••------------------•----------••-----------•--•--------•-••----------• --•--•--------•------••----._...----••-•-••-••-••--•---------- U Nature of Repairs or Alterations—Answer when applicable_--.--- -`: 16L.l�_--__•-----�1---------� EW-Z,�---_---6_1 ( �. .. 4 ................. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iITIE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operati n until a Certificate of Compliance has been issued by the board of health. Si nedQ -_ Aplication Approved By......_. ._._�__._y ...... -------•--•-------- ------. Date Application Disapproved for the following reasons:----••----------------•---...---------------------------------•--------------------------------------.........._ ....................•-•--------------•----------------------...........---•-----------........------------•-•---•-•--•--•--•-----••-------•-----•••-•-•••••••----•----------••------•--------•--•------- Date PermitNo......................................................... 1 Issued....................................................... Date a A V M . Na677 Fins...�. ...................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH O'.••�.....................O F........'V 4 - ................................................... Appliration for Disposal Works Tonstrurtiun thrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System _-- - -•• ----------------------� ..f y ......................................... ion-Adores or r�t ........._.....�.:. ._.. t....___..L ..-•---•........... .........v�?.........._..__��z'•- -.4t&&V5............................... Owner Addres ........................... �. Installer Address dType of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building .....................:------ No. of persons___•-____-__-______-•__-____ Showers ( ) — Cafeteria ( ) aOther fixtures ..----•--•-- - -----•-•-----•-•----------•-•--•---•-----__-•--------------------------------------•------•••------- W Design Flow............................................gallons per person per day. Total daily flow............................................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.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution.box ( ) Dosing tank ( ) aPercolation Test Results Performed by........................................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Gz, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ •---•-•--•-•-----------------------------------------------------------------••----•-........................................................................ ODescription of Soil.............................................................................--------------------------------=--------------------•-----•-----•---------------•-•---••- x W ----••-----•----•--•-----------------------------------•---------••---•----•--------•---------••---•- n �S U Nature of Repairs or Alterations—Answer when applicable.____-_ 1- ____ -�1 ---- ------ ......•-•-• ------------------------------------------------------------------------------------------------------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iITI=Z 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operati n until a Certificate of Compliance has been issued by the board of health. Sined--- .: ? ...............:.�E !�!st�--. f 1 Date Alication Approved By...... ' '--- � -** ------------•------------------ ------ � '� ... Date Application Disapproved for the following reasons:................................................................................................................ Date PermitNo......................................................... Issued_....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH . ►- ..............OF......14 ,sf, .......................................... Tntifiratr of Toutplittnrr THIS IS TO CERTIFY, That tie Individu Sewa��ff Disp sal System constructed ( ) or Repaired (1+✓' by .�..'� ..:: - t �..__....----•--•-------------------------------•----......_..._.........-•---__•- at----------- r ................� w------ Q Inst -_-•- 7�' .......--1'*,ee------ ........................................ 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 SHALT. NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. �,/� 2. JJ ------ DATE............. .- . .........Atir -------------------•------- Inspector { ---------------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .......... !v'..............0F...... :: .�...�✓ .......................................... N `�.... FEE........................ Disposal Vorkp Tonstynrtil 0. ga!Z61 Permission is herebyra a __. to Construct ( ) or R eUak., ) an I divi`ual Sewage Disposal System# atNo .. _..__c .......... fin '............1 ---' 1 __ .................................................•-------_...... ...... Street as shown on the application for Disposal Works Constructio ermit No.................... Dated.......................................... --- - -------•- A B rda of =---.--••------------................. Health, DATE.� -1�7 / ----•-------------------------------•••....... - \ FORM 1255 HOB69 & WARREN. INC.. PUBLISHERS