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HomeMy WebLinkAbout0056 BOXWOOD DRIVE - Health } 56 -Boxwood Drive. W. Barnstable'' F A = 216 058 r No. 4210 1/3 BLU 10% CERTIFICATE OF ANALYSIS Page: 1 o Barnstable County Health Laboratory grs�cr3u5�� Report Prepared For: Report Dated: 3/12/2009 David McCarthy Order No.: G0950876 56 Boxwood Drive West Barnstable, MA 02668 Laboratory ID th 0950876-01 Description: Water-Drinking Water j I Sample#: Sampling Location: 56 Boxwood Drive West Barnstable MA Collected: 3/9/2009 Collected by: D.M. Map 216 Parcel 058 Received: 3/9/2009 i Test Parameters ITEM RESULT UNITS RL MCL Method# Tested Nitrate as Nitrogen 1.7 mg/L 0.10 10 EPA 300.0 3/9/2009 Sodium 35 mg/L 5.0 20 SM 3111 B 3/1 -_009 I pH 6.6 pH-units 0 SM 4500 H-B 3/9/2069 Sodium level is above the rnaxium contaminant level. Those on a low sodium diet may wish to consult a physician. Attached please find the laboratory certified parameter list. Approved B ?Dr ( ector) r ` 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 w � Page: 1 t° Barnstable County Health Laboratory ysscHl} uS% Report Prepared For: Report Dated: 5/29/2008 Dana&Melissa McCarthy Order No.: G0846347 56 Boxwood Drive West Barnstable, MA 02668 Laboratory ID#: 0846347-01 Description: Water-Drinking Water Sample Sampling Location S Box odWDr: -BansebAle Collected: 5/27/2M8 Collected by: M.McCarthy Received: 5/27/2008 Routine ITEM RESULT UNITS RL MCL Method# Tested Nitrate as Nitrogen 11 mg/L 0.10 10 EPA 300.0 5/27/2008 Copper 0.42 mg/L 0.10 1.3 SM3111B 5/29/2008 Iron ND mg/L 0.10 0.3 SM 31 11B 5/29/2008 Sodium 30 mg/L 1.0 20 SM 311113 5/29/2008 Total Coliform Absent P/A 0 0 SM9223 5/27/2008 Conductance 510 umohs/cm 2.0 EPA 120.1 5/27/2008 pH 7.2 pH-units 0 SM 4500 H-B 5/27/2008 Nitrate level is above the recommended maximum contamination level for drinking water. Retesting is recommended.Sodium level is above the maximum contaminant level. Those on a low sodium diet may wish to consult a pleysician. Approved B ___ 1� (Lab rector) W .? J Q &j N CC4 ND=None Detected RL = Reporting Limit MCL=Maximum Contaminant Level Superior Court House, PO. Box 427, Barnstable, MA 02630 Ph: 508-375-6605 i - Page: 1 U M CERTIFICATE OF ANALYSIS Barnstable County Health Laboratory RECEIVED 3�sS'�CHIiSW. Report Dated: 6/3/2004 Report Prepared For: Order No.: G042 366JUN 0 7 2004 Donna M. Maloney Kinlin Grover GMAC Real Estate TOWN OF BARNSTABLE P O Box 156 HEALTH DEPT. Barnstable, MA 02630 Laboratory ID#: 0425366-01 Description: Water-Drinking Water Sample#: 25366 Sampling Location 56 Boxwood West Barnstable MA Collected: 6/1/2004 i Collected by: D Maloney Received: 6/2/2004 Routine i ITEM RESULT UNITS RL MCL Method k Tested LAB: IC Lab Nitrates 5.3 mg/L 0.1 10 EPA 300.0 6/3/2004 LAB: Metals Copper BRL mg/L 0.1 1.3 SM 3111 B 6/3/2004 Iron BRL mg/L 0.1 0.3 SM 3111B 6/3/2004 I Sodium 20 mg/L 1.0 20 SM 3111B 6/3/2004 LAB: Microbiology i Total Coliform Absent P/A 0 Absent 309 6/2/2004 LAB: Physical Chemistry j Conductance 210 umohs/cm 1 EPA 120.1 6/2/2004 pH 5.9 pH-units 0 EPA 150.1 6/2/2004 Sodium level above the average.Those on a low sodium diet may wish to contact a physician. Sample has higher than average levels of Nitrates. Monitoring is recommended(2-3 times per year)to establish any upward trends. Approved By: <:f� L ab Director) Superior Court House, PO. Box 427, Barnstable, MA 02630 Ph: 508-375-6605 TOWN OF BARNSTABLE C. LOCATION y 6 .0"ek.00 A PA- � SEWAGE Q o® ?U VILLAGE 14.es'f d�s9Z.� rt a C ASSESSOR'S MAP & LOT2Z� INSTALLER'S NAME&PHONE NO. PAS70- V SEPTIC TANK CAPACITY /400 LEACHING FACILITY: (type) -2'ci o© 64 C 19r a' (size) U X of g� NO.OF BEDROOMS �- BUILDER OR OWNER Y<- PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any�wetlands exist within 300 feet of leaching facility) Feet Furnished by 53 � 3 2 i No. D Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes " PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Zipphration for ]Di6pozar bp5tem Congtruction Vermit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) El Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. Assessor's Map/Parcel 2 1 6/0-5 9 (lJ. �(f — spM a �a Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel No. aasrc�.O.- -mac_.v A-.r a7-J 472 -ci 3oo 5'14 0 Y 3 Type of Building: Dwelling No.of Bedrooms Lot Size 15,005sq.ft. Garbage Grinder( ) Other . Type of Building RFS i O. No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow 3331,. , gallons. Plan Date Number of sheets / Revision Date Title Size of Septic Tank Type of S.A.S. `L r°,P (roe oe") Description of Soil 0 1 Q' t .3 , i O S b" LS , ZN SL Nature of Repairs or Alterations(Answer when applicable) 14E TF_R -To Pt..AA)5 Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been is ed this Roard of Health. Signed1"IflIj `O Date Application Approved by Date Application Disapproved or the following reaso Permit No. Mu Date Issued �- --———— ————————————————————————————————— — . ✓ 4, r jd'^'J i ,.� ! r� � t• 'e. r� i.J ,_ a r No. Y a Fee k THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: .� Yes l/ N PUBLIC�H_EALTH DIVISION -TOWN OF BARNSTABLES,MASSACHUSETTS 12pplicafion for ;ig ogaf pgteut �ottgtruction Permit Application for a Permit to Construct( )Repair 4 Y Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No.5/ ( (,vcop pQ Owner's Nagme,Address and Tel.No. $ Assessor'sMao/Parcel .2161058 30fl,14,J* /, S M C ti installe's Name,Address;and Tel.No. Des' ner's Na ,Address and Tel.No. A�bc�, a� 4Z me 3vv NAY fiuv+(2c�M 83 6r��tJt_;' ftD SANDu�►c;N , c> to-A GZ? . �. F'pa400r�4 Type of Building: + Dwelling No.of Bedrooms 7' Lot Size 154 005sq.ft. Garbage Grinder,( ) Other Type of Building fZGS p No. of Persons Showers( ) Cafeteria( Other Fixtures i i Design Flow 33 0gallons per day. Calculated daily flow 331,r galloas. Plan Date �'�'� Number of sheets Revision Date Title Size of Septic Tank OOa Type of S.A.S. Z GN�Md�+25 50o F1 v�,/� Description of Soil 0- 1 O r LS , 10 3�0� L$ , Zit " I CO$� SL Nature of Repairs or Alterations(Answer when applicable) Date last inspected:. Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been iss edMsBoard of Health. Signedxo m Date G . /-O t// s Application Approved by 1 /,C� a ----� Date Application Disapproved for the followinyg reason Z V Permit No. / Date Issued , 564 �(3�61 tJ THE COMMONWEALTH OF MASSACHUSETTS f .'BARNSTABLE, MASSACHUSETTS �1 Certificate of (Compliance THIS IS TO CJSRTI17Y, that the On-site Sewage Disposal System Constructed( )Repaired ( )Upgraded( ), Abandone ( ) .y 11. r r at _ oXl —. r �S�t^►" ^ ha constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. %'dated Installer _r`"LLJ� Designer The issuan-e o his'�pee=xi shall-not-be-construed-as-a-guarantee that the sy �Mill f on as l• ne���^ Date / `, U t Inspector 1 ,. �------------------------Fee— �./ r � THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Migogar *pgteut on!9truction permit Permission is hereby gran o to Con trucy ( �),R�e}�ailr� �Upg?ade(�1' )'A Abandon(`j)> y ('� " System located at t!(�VJ �/ 1/V 0 / and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Constr:ch u us a ompleted within three years of the date of t '�per it✓~ Date:_ / +� Approved by /9-5 08/04/2014 03:09 FAX 16001/001 Town of Barnstable Regulatory Services Thomas F.Geiler,Director • BARNBfABLB, • i639• 1659. Public Health Division oTpO � Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office; 508-862-4644 Fax: 508-790-6304 Installer& Designer Certification Form Date: Q Designer: b2d4.A Installer: Address: 2 . 7ink ("ZI Address: �a�mn�n. MPS oaS� On 5QRJQ4 was issued a permit to install a (date (instal er septic system:at_s(,# t ,�c�C6 3. asm ased on a design drawn by (address) 13•l 19nQKDM=0S&\ dated Q ( esigner) GCS_ I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateraI relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State & Local Regulations. Plan revision or certified as-built by 4esigner to follow, OF AdgS iV Z1� �C CARMEN tiN 1 ure E. SHAY N y No_ 1181 0 IST 5,4A11 (Designer's Signature) (Affix Desi Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q:Health/Septic/Designer Certification Form TOWN OF BAMSTABLE C LOCATION �7 ®xik.00 A SEWAGE # O - '® �1 _os8X, . VILLAGE J&-dj°( ASSESSOR'S MAP & LO INSTALLER'S NAME&PHONE NO. f.oCTO,.-r SEPTIC TANK CAPACTTY' ' t40 0 LEACHING FACII.ITY:-pe) �-�i 100 64 e.49 (size) NO.OF BEDROOMS - BUILDER OR OWNER 1 ;PERMIT DATE: �-/-O`t COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any'wetlands exist within 300 feet of leaching facility) Feet Furnished by 13`� t Dec COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: Owner's Name: gg lw Owner's Address: C/O _,4n� �`�� a".40t Date of Inspection: /7 v� 5 4 n / Name of Inspector:(please print) Josepb M.Martins Company Name: Aceu Sepcheck Mailing Address: 17 Northside Dr., S.Dennis,MA 02660 Telephone Number: 508-385-5891 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper fimction and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ((ww Passes S� \ ,0 V l r'' S ��s onditionally Passes i U s er Evaluation by the Local Approving Authority I O}� �oe e(n l �ip, I , s 41 Inspectors Signatur Date: 1 0 t � �\O,) The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.if the system is a shared system or has a design flow of 10,000 GO gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the i 5 DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving (� authority. Ck f- . 1) Soil absorption system consist of 2 leach pits stacked one atop the other. Engineer Notes and Comments: design considered only bottom 3.5'of bottom pit for sidewall leaching.Liquid level is above this. 2) Dbox is corroded and need s to be replaced. 3) Pumping recommended (" next full year of service. 4)At time of inspection a broken milk type container was P ` found right next to the well containing 1 quart of an oily sludge. Recommend well 1��S 0 ` testing for oil and grease,VOC,and coliform. `niQCQ � ok � 2 J ' Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A, CERTIFICATION(continued) Property Address:.. Owner: 56 Boxwood Drive, West Barnstable,MA Date of Ins White pecbion: 1/03/2004 Inspection Summary: Cheek A,S,C,D or E/ALWAYS complete an of Section D A System Passes: l have not found any information which indicates that the failure criteria described in 310 CUR 15.303 os in 310 CMR 15.304 exist.Any failure criteria evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements.If`snot determined'please explain. The septic tank is metal and over 20 years old*or the septic tank er metal or not)is structurally unsound,exhibits substantial infiltration or exfaltradon or tank fail s imminent.System will pass inspection if the existing tank is replaced with a complying septic tank as app by the Board of Health.. sA metal septic tank will pass inspection if it is stru sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is able. ND explain: Observation of sewage p or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a en,settled or ura=n distribution box.System will pass inspection if(with approval of Board of Health . broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: Page 3 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Owner: 56 Boxwood Drive, West Barnstable,MA Date of Inspection: White hire 004 C. Further Evaluation is Required by the Board of Health: `� Conditions exist which require further evaluation by the gad of Health in order to determine if the is failingto protect public heal sa �t�° Pr pu health, fay or the environment. 4e'e' J " � pffl�t- L System will pass unless Board of Health determines in accordance with 310 CNIR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2- System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is flmetiioning 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 Unk 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and The presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria an triggered.A copy of the analysis must be attached to this form. 3. Other: Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 56 Boxwood Drive, West Barnstable, MA Owner. White Date of Ingm tion: 1/03/2004 D. System Failure Criteria applicable to all systems: You must indicate`Yes"or'to"to each of the following for all iinspections: Yes No = ?,es -eVA&A^ Backup of sews a into.facili stem 8 ty sy conhponent due to overloaded or clogged SAS or cesspool —6l 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 duc to an overloaded or clogged SAS or cesspool `�Liquid depth in cesspool is less than 6"below invert or available volume is less than Vz day flow —if"Requhred 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, _b/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. �-.� y portion Of a cesspool or privy is within 50 feet of a private water supply well. y Pomace 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. ['Phis system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free fFomi pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis mast be attached to this form,] (Yes/No)The system fair.I have determined that one or more of the above failure criteria exist as described in 310(:MR 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 most serve a faci' a design flow of 10,000 gpd to 15.000 gld- You must indicate either"yes!'or"no"to each of the folio (The following criteria apply to large systems in addition the criteria above) yes no the system is within 400 feet of a stir drinking water supply the system is within 200 feet tributary to a surface drinking water supply the system is located in nitrogen sensitive area(Interim Wellhead Protection Area--IWPA)or a mapped Zone 1I of a public er supply well If you have answered" to any question in Section E the system is considered a significant threat,or answered "yes"in Section D a the large s t g ys cm has failed. The owner or operator of any large system Considered a significant threat der Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The owner should contact the appropriate regional office of the Department. Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: . 56 Boxwood Drive, West Barnstable,MA Owner: White Date of inspection: 1/03/2004 Check if the following have been done. You mast indicate` es"or"no"as to each of the following: Xo Pumping information was provided by the owner,occupant,or Board of Health "Z*ere any of the system components pumped out in the previous two weeks? 1 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 NIA) -L— Was the facility or dwelling inspected for signs of sewage back up? !/— Was the site inspected for signs of break out? Y _ Were all system components,excluding the SAS,located on site 7 _✓_ba Wcrc the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the ftes or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? V/ Was the Facility owner(and occupants if different from owner)provided with information on the r er maintenance of subsurface sewage disposal systems 7 p The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Xes �o t/ Existing information.For example,a plan at the Board of Health. _�_ Determined in the field(if any of the failure trite is related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] Page 6 of l I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 56 Boxwood Drive, West Barnstable,MA Owner: White Date of inspection: 1/03/2004 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 0 Number of current residents: Does residence have a garbage grinder(yes or no): NO Is laundry on a separate sewage system(yes or no):AN[if yes s p� required] Laura system i separate inspection r � y inspected(yes or no): Seasonal A- Seasonal use:(yes or no):� /0 5 Year Steer meter readings,if a�able last 2 y�rs us3 a(gpd)): (� P pump(ye or no). d Last date of occupancy: OC r 1 Z 00 3 COMMERCIAL4NDUSTRL4L Type of establishment: Design flow(based on 310 CMR 15.203): Basis of design flow(seats/persons/sgg,etc,): Grease crap present(yes or no): Industrial waste holding tank present(yes or _ Non-sanitary waste discharged to e 5 system(yes or no): Water meter readings,i e: Last date of cy/ e: OTBER(describe): Pumping Records 0 GENERAL INFORMATION Source of information: r y✓I'1pe4 / eArldl� Was system pumped as part of the inspection(yes or no):JV J If yes,volume pumped:____gallcns--How was quantity pumped determined? Reason for pumping. TYP3 OF SYSTEM eptic 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/Altemative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank _Attach a copy of the DEP approval Other(describe): Approximate age of all components date ins led(if own)and source of' fo on,An 141V J , / Il Were sewage odors detected when arriving at the site(yes or no):—NO I Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:. Owner: 56 Boxwood Drive, West Barnstable,MA WhiteDate of Inspection; 1/03/2004 BUILDING SEWER(locate on site plan) t Depth below grade: --1- Materials of construction: cast iron _!�40 PVC_other(explain): Distance from private water supply well or suction.line: > /n Con ents(on condition of ioints,venting,evidence of leakage,etc.): ' SEPTIC TANK:—(locate on site plan) Depth below grade: 1/ Material of consttuctio� ✓concrete metal fiberglass_polyethylene _othea(explaia) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) 1��(y 517 Dimensions: �/0 V Sludge depth: Distance ce from top of in f S Ige to bottom of outlet tee or baffle: I Scum thiclmess:Distance from top of scum .� Q1 to top of outlet tee or baffle: l Distance from bottom of scum to bottom of d tee or baffle: I How were dimensions determined: G'(l U S C (, �ud Comments(on pumping recommendations,inlet and outlet tee'or baffie crnndi on,structura integdty,liquid levels as related to outlet invert,eviden of leakage,etc.): 2 Sony wka� c�t�V 0 dP� .p GREASE TRAP:_(locate on site plan) Depth below grade._ Material of construction:_concrete meta _fiberglass polyethylene other (explain): Dimensions: Sewn thiclmess: Distance from top of scum to top outlet tee or baffle: Distance from bottom of s bottom of outlet tee or baffle: Date of last pumping. Comments(on pumpin ecommendations,inlet and outlet tee or bale condition, structwal integrity,liquid levels as related to outlet' ,evidence of leakage,etc.): Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 56 Boxwood Drive, West Barnstable, MA Owner: White Date of Inspection: 1/03/2004 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglas _polyethylene other(explain): Dimensions: Capacity: ons Design Flow: s/day Alarm present(yes of no): Alarm level: in working order(yes or no): Date of last pum Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: (if present must be openedxlocate on site plan) Depth of liquid level above outlet invert:_A_r /li vegr , Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of ,etc.): D boyS f^ A c W moTs .AzLeu DR . PUMP CHAMBER: (locate on site plan) Pumps in working order(yes or no Alarms in working order(yes or n Comments(note condition o p chamber,condition of pumps and appurtenances,etc.): Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: �! Date r:Inspection; 56 Boxwood Drive, West Barnstable, MAWhite SOIL ABSORPTION SYSTEM l/03/200 (SAS).- (locate on site plan,excava Ion not required) If SAS not located explain why: h A.A , Type Zleaching pits,number: �- leaching chambers,numoer: � `q� St1aI�N UN� leaching galleries,number: s leaching trenches,number,length: o leaching fields,number,dimensions: 41 Lit L®rtj. overflow cesspool,number: innovative/alternative systems Type/name of technology: f4 Comments(note condition of soil,signs ofhydraulic failure,level of ponding,damp soil,condition of vegetations etc.): 1 L 1 4 14 v 1,0 XPve( /n is 7— // n 62&SP� 944 tx ScvoG,E o A) Ta,o dG 807��1 i r. CESSPOOLS: (cesspool must be pumped as part of inspectionxlocate 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' (yes or no): Comments(note cond' - of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: (locate on site plan) Materials of construction: Dimensions: Deptlx of solids: Comments(note condition of soil,signs of h ulic failure,level of ponding,condition of vegetation,etc.): Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: 56 Boxwood Drive, West Barnstable, MA Date of Inspection• White 1/03/2004 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at lcast two permanent referenice landmarks or benchmarks.locate all wells within 100feet.Locate where public water supply,enters the building. � GVeI� � C A� � 3 2 � i �-3 r7s�'93 =a7,5 Page 11 of 11 A n OFFICL41 INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: 56 Boxwood Drive, West Barnstable,MA Date of Iuspectiop: White SITE EXAM 1/03/2004 Slope Surface water Check cellar Shallow wells �, Lf S /`/Q/lij�/�►Q(� � �2�J Estimated depths to ground water;, 'f 2- 3 r r"A 44A—_ � ! r— 13 s p-oAl 4zz7rs Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed; Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-cxplain: Checked with'local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: 1, See S a 0-o I ♦ y 2- - G leaclo?�( welew- can fb vvr s 3.s -S . L 3 . �. �` THE FOLLOWING IS/ARE THE BEST IMAGES. FROM POOR QUALITY ORIGINAL (S) DATA Compli'menU0 , EXPRESS Cover Shut. R R,N FAY : 50g-240 058 To: From:.. 6 Fax# (,e* Phone1# ( Date: / 0 Urgent D Confiderittal0 Conti'ni Receipt Number`bf Pages' Reply Fax#: (Inc(uding Cover) Z. Message: : trrMeN•. .f'>e,.i �f:. ; tN; - :9� _ _•`�,�s•.,��,�:. .:r!:._ _ Y�._":� _ _ "! 7 ilk, Afl� 'd Ag� - �p� 4J — 4v ,,";...o �s.:. ,.fir^, - .•q:. ..f a dam° J �•1 p;tr: +v1: ;pn 1 r 4 4' '+IY. - q:.> _ •I� .. ...r .. .., ... .. f 6 t:•� �, f.5 t .... .... .. �u. a b�FF'J' f ,7 i Cl. If - r - Add. Pages Domestic: Qty X ate_ t TOTAL FAX EXPRESS COST: E : T�ferrk[-frOnAl t"Vw r &fAJ A/D r- b{ d onc. Get-Mii raa x Plea 5 e brIA � ,�ssoc�ctfe �r�SS/SrtvtC,�- Complimentary FAX ' EXPRESS Cover She et RenRN FAX: 5og-Z40 - 0561 To: From: sTXlqa, Fax # J Phone # g— P Date: ( � 3 V O Urgent ❑Confidential❑Confirm Receipt Number of Pages: Reply Fax#: (Including Cover) Message: Fax Pricing ( Add. Pages Domestic: Qty X S 1 = S 3�1 �59 1 TOTAL FAX Cq L S y f toha/ f�t,XCs dftN ND T be_ c1 o/)G G�t'f�1i5 ho�.X, /�/�cc 5 e brim � .Assac�ct:f-c� LOCATION � SEWAGE PERMIT NO. Ac VILLAGE 1.RSTA LLER'S NAME & ADDRESS ue B U I-1 D E R OR OWN M 6 G�,yi T DATE PERMIT ISSUED l�- • -�� DAT E COMPLIANCE ISSUED 7k I! ` ii a 1% COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF,ENVIRONMENTAL AFFAIRS F DEPARTMENT OF ENVIRONMENTAL PROTECTION Y t MAP PARCEL, LOT --- F'�'j 2 2004 TITLE 5 BARNSTABLE OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS'DEPT. SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: �tl/ AP)Waloof bell/el AV 4r-islWe 4 /v IV4 Owner's Name: C/v ��� � /l W Jo Owner's Address: / , •(�' ! (� h keDate of Inspection: 7 �' ��VS 4 nSf:/ zq Name of Inspector: (please print) Joseph M.Martins FAILED INSPECTION Company Name: Accu Sepcheck p Mailing Address: 17 Northside Dr., S.Dennis,MA 02660 Telephone Number: 508-385-5891 1;_N Kk Uha w ply 1414 't_�hNI W CERTIFICATION STATEMENT i 12(1 O $ 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 fimction and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15340 of Title 5(310 CMR 15.000). The system: Passes --,�onditionally Passes V Needs F er Evaluation by the Local Approving Authority 'Is -Inspector's Signature Date: Q 3 The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving ,authority. 1) Soil absorption system consist of 2 leach pits stacked one atop the other. Engineer Notes and Comments: design considered only bottom 3.5'of bottom pit for sidewall leaching.Liquid level is above this. 2) Dbox is corroded and need s to be replaced. 3) Pumping recommended next full year of service. 4)At time of inspection a broken milk type container was found right next to the well containing 1 quart of an oily sludge. Recommend well testingfor oil and ease VOC and colif grease, , orm. Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 56 Boxwood Drive, West Barnstable, MA Owner: White Date of Inspection: 1/03/2004 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 the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements.If`not determined"please explain. The septic tank is metal and over 20 years old*or the septic tank er metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank fail s imminent.System will pass inspection if the existing tank is replaced with a complying septic tank as appr by the Board of Health.. *A metal septic tank will pass inspection if it is stru sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is able. ND explain: Observation of sewage ba p or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a en,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health . broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: r Page 3 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 56 Boxwood Drive, West Barnstable, MA Owner: White Date of Inspection: 1/03/2004 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. -&Q 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(l)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well".Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: 1� Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 56 Boxwood Drive, West Barnstable, MA White Owner: 1/03/2004 Date of Inspection: D. System Failure Criteria applicable to all systems: You must indicate`yes"or"no"to each of the following for all inspections: Yes No , — pws ,QVX&AA � Backupof sewage into facili stem component due to overloaded g ty system po 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%z day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped 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. _ �l y portion of a cesspool or privy is within 50 feet of a private water supply well. �y 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 coliiform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system most serve a facili 'th a design flow of 10,000 gpd to 15,000 gPd• You must indicate either`yes"or`no"to each of the folio (The following criteria apply to large systems in addition the criteria above) yes no the system is within 400 feet of a sur drinking water supply the system is within 200 feet a tributary to a surface drinking water supply the system is located in nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone Il of a public ter supply well If you have answered"y 'to any question in Section E the system is considered a significant threat,or answered "yes"in Section D a ve the large system has failed.The owner or operator of any large system considered a significant threat der Section E or failed under Section D shall upgrade the system in accordance with 310 CUR 15.304.The owner should contact the appropriate regional office of the Department. Page 5 of 11. OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 56 Boxwood Drive, West Barnstable, MA Owner: White Date of Inspection: 1/03/2004 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 _ -,,z*ere any of the system components pumped out in the previous two weeks? 1/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) _tL Was the facility or dwelling inspected for signs of sewage back up? JWas the site inspected for signs of break out? Were all system components,excluding the SAS,located on site? _V"'_ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition o-f theba/ ffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? V Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes po 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(3)(b)) i Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address; 56 Boxwood Drive, West Barnstable,MA Owner: White Date of Inspection: 1/03/2004 FLOW CONDITIONS RESIDENTIAL 2 Number of bedrooms(design): 3 Number of bedrooms(actual): J DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): S Number of current residents:_0 Does residence have a garbage grinder(yes or no):NO Is laundry on a separate sewage system(yes or no):,Q f�j[if yes separate inspection required] Laundry system inspected(yes or no Seasonal use:(yes or no): �Pa r 12',of Water meter readings,if available fa'-�fye'a'0rs'j!sagVe(gpd)): We(rim Sump pump(yes or no): AJd Last date of occupancy: QC_ 1 2 00 3 COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): pd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or _ Non-sanitary waste discharged to e 5 system(yes or no):_ Water meter readings,i le: Last date of cy/use: OTHER(describe): GENERAL INFORMATION Pumping Records ^ � /J Source of information: QMJ 24 ?-o0 / Pere ,etc, 6 I1�We&ON Was system pumped as part of the inspection(yes or no):VV J If yes,volume pumped: gallons--How was quantity pumped determined? Reason for pumping: 7OF 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/Altemative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank _Attach a copy of the DEP approval Other(describe): Approximate age of all componTA date insta ed(if own)and source of' fib ation• � a Were sewage odors detected when arriving at the site(yes or no):Y Page 7 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 56 Boxwood Drive, West Barnstable,MA Owner: White Date of Inspection: 1/03/2004 BUILDING SEWER(locate on site plan) Depth below grade: ;�— t Materials of construction:_cast iron 40 PVC_other(explain): Distance from private water supply well or suction line: > _ Conupents(on condition of joints,venting,evidence of leakage,etc.): A-OaM SEPTIC TANK:_(locate on site plan) Depth below grade: it Material of construction: ✓concrete metal_fiberglass_polyethylene _other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):—(attach a copy of certificate) 1� Dimensions: �/0 G X 7 Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle:A Scum thickness: /3'1 1' Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of utl baffle: tee or bae: I How were dimensions determined: ilk U .S C Ludm tvdcvq- Comments(on pumping recommendations,inlet and outlet tee'or baffle condi on,struct ura integrity,liquid levels as related to outlet invert,evidencq of leakage,etc.): 2 � w�uf Cv�v a c�PG� v Q rftL GREASE TRAP: (locate on site plan) Depth below grade:_ Material of construction:_concrete meta _fiberglass_polyethylene_other (explain): Dimensions: Scum thickneZscbottom Distance fromop outlet tee or baffle: Distance frombottom of outlet tee or bale: Date of last pu Comments(onmendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to oence of leakage,etc.): Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 56 Boxwood Drive, West Barnstable, MA White Owner: 1/03/2004 Date of Inspection• TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fibergla polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: day Alarm present(yes or no): Alarm level: in working order(yes or no): Date of last pum Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX:Zof present must be opened)(locate on site plan) Depth of liquid level above outlet invert: v Kr Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of�o ,etc.): 0 S� S r,1-0dod arJ 6 rectckd (N fov PUMP CHAMBER: (locate on site plan) Pumps in working order(yes or no): Alarms in working order(A�®rComments(note conditionchamber,condition of pumps and appurtenances,etc.): Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: 56 Boxwood Drive, West Barnstable,MA Date of Inspection: White SOIL ABSORPTION SYSTEM(SAS): 1/03/200 ( ) (locate on site plan,excava on not required) If SAS not located explain why: .'� Type leaching pits,number: leaching chambers,numoer: Pee Iqol, I)Akt, leaching galleries,number: leaching trenches,number,length: ll,t ltQ IQvC�- 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.): -nov 1 L1 ► 414v1,0 XP1%e( /A /s' 7— 1 l< CESSPOOLS: (cesspool must be pumped as part of inspectionVocate 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' ow(yes or no): Comments(note condi ' 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 h uli�failure-, vel of ponding,condition of vegetation,etc.): Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 56 Boxwood Drive, West Barnstable, MA Owner: White Date of Inspection: 1/03/2004 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building. 11 Gtle lr1 C 3 �- 3 C , 13 -6-T C we/I - YS 50s, ` 4 , Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: 56 Boxwood Drive,West Barnstable,MA Date of Inspection: White 1/03/2004 SITE EXAM Slope Surface water Check cellar Shallow wells / !{j /✓0/r'1//1 q�- ✓�l �/�� 1 Estimated depth to ground water Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) 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: Z • G ,ea���t ��>�� car /'P 3 • � f THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ► ......... . .0F...... ........................... ......... Appliratinn -for Uiipusal Workii Tnnstrnrtion Vrrniit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: - %4__. v_.1� s� l�---- R!VC7.....-- •..... ��� l�J ��! L .....-------•--•-•--------- lJ Location-� T�Ar LT.ddress /p t No �A . 2 Owner Address Installer Address UType of Building Size Lot....l: �.�>........Sq. feet -, Dwelling—No. of Bedrooms._-.___:5.__.----------------------------Expansion Attic (Pb) Garbage Grinder (Alb) Other—Type of Building ----- No. of persons---------------------------- Showers ( ) — Cafeteria ( ) d Other fixtures ---------- -W Design Flow---------11V............................gallons per Total ally flow----.� .......................... WSeptic Tank—Liquid capacitv/� �__gallons Length..��.�._... Width.. ._.. . lliameter_.........__... Depth.__.____...._ x Disposal Trench—No----------------_-- Width-------------------- Total Length------------------.. Total leaching area--------------------sq. ft. Seepage Pit No.......I......... Diameter....../.0...... Depth below inlet.................... Total leaching area---4�.....sq. ft. z Other Distribution box ( ) Dosin tank ( )/� pp Percolation Test Results 2 Performed by._ l�brl4_(.1�_lf:__ L (�.D__...6_�S_:...._.__ Date...... d_GT_-----�_ Test Pit No. 1... __ ---nunutes per inch Depth of Test Pit._ r�........ Depth to ground water. _-_.¢;,a_" " - w Test Pit No. 2..... :..3__niinutesper inch Depth of Test Pit-------L_1'}_....... Depth to ground water------------------------ a ------------------------------------------------------------------------------•------------------•-•---------------------•----------------------------- G Description of Soil--.- _ =/.q....__LDI�-h-.__.5c�Q-sol. -- -'----1.&-_..- W s 0--------------- �..._ .,: : . ::: 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 Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signd--- ..... _-�- -- --- e--------------------- AApplication Da e A . - ....-•---•......--- ---------------------------------------- PP Approved B Y f = � Date Z / Application Disapproved for the following reasons-----------------------------------•---.._...............-----•----------------.... ............................ --------•---------------------------•---------------•---------------------------------------------------•------------•.......-- --•-------•-------------•----------------------------------------------- Date Permit No......................................................... Issued �S ? te....... ---- ----- _--------- Date------------------------------- F �771 No.---•. ................ ....... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH . ......OF.-.: ..�i.. .>..i—:. �1 .G.. '".................................. . pphrtt#ion -for Bispuiittl Works Cn>amaur#iou Vami# Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ,T. --•---•--.............c..X i....c> ./c.......... ......• Jc.. i/_r ' _.1_ _? .�..L ............................ Location-Address_ or Lot No.. ' t1 -2Tl- ------------•---•----•---.----- .......... + t Owner - Address •- W - Installer Address Type of Building Size Lot..... _-� .._.._.Sq. feet Dwelling—No. of Bedrooms------�..,�`..................................Expansion Attic (J b) Garbage Grinder a No. of persons............................ Showers ( ) — Cafeteria Other—Type of Building .....A1141----------- ( ) a' s Other fixtures ---------------- ---------------- W Design Flow---------/f./�_._....-----•---------------gallons per #0We/ day. Total daily flow___;. - ----------------------------gallons. WSeptic Tank—Liquid capacitv/'�OU...gallons Length_ f'(__ Width.` -.._�.o.. Diameter_----..-._.---_ Depth.-_-..-.....-.- x Disposal Trench—No..................... Width-------------------- Total Length-__-____-__-•-___--. Total leaching area-----.--_--.-----.-sq. ft. Seepage Pit No.-___-_-L_.._...._.. Diameter...._O_-----_ Depth below inlet____________________ Total leaching area_1w_----_sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed ...... ........... Date------6. ,2 Test Pit No. 1_.L-._2___.mmutes per inch Depth of "Pest Pit.-. ........ Depth to ground water-_-----------------_- 1:14 Test Pit No. 2___L___3___minutes per inch Depth of Test Pit.._..J_6......... Depth to ground water---------------------_ a ------------------------------------------------------------------------•-----------------! ---------'.-------•----�---•t•-'----------•-t---�----_-_- rt--f--.---------------{-- O Description of Soil--- l L!)P_ y------ ----------h/ ------------------5A.-'A-- ------- ----------- '�-W ---------------- --------------------------------------------------------- '` 't�' ,.�i, I z` r x �-- J��.ter.---•--==--------------------- ------------------------ 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 Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by/the board of health. Sig ed.. r "L U#��4:t---------------------- Application Approved B Y TT / ---------------•......._.. ..............Date Application Disapproved for the following reasons_______________________ ___________________________________•_ ••--••-•--•---------•-•-----.---•----------------------------•-•---------------•----•-•-•--------------•-----------•---••---------.---------•-•-•-•---------•----------------•------ Date PermitNo....................... ---------•----- ...... Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH T .............OF......... '.Ct ::e� v_�r.. ............................... �rx#ifirtt#p�>af'�;f�um�Iitta�rle TH IS C & Y, That the Individual Sewage Disposal System constructed (Y ) or Repaired ( ) by- ato.... ... Instal I l at " ��� �� - U _-...__._. has been installed in accordance with tie provisions of Attic e X of The State Sanitary Code as described in the application.for Disposal Works Construction Permit Nod.....7----71----------------_- ----------------------- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE-------------------------------------------------------------------------------- Inspector...................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .....ti�r�c ��/ 0: 7 FEE--- ' -f-------- a �i��alatt # r#ioatrrmi# Permission is hereby granted------ -----ot... --••• ..........!P4 ...----`---•-•-------------------------------------------------------•--•---•.---•-- to Construct (�) or Repair ( ) an Individual Sewagesal System i �r Ems' ` /t.J Atreet as shown on the application for Disposal Works Construction Permit No--------------------- DatedJ__%_'_1.--.%,f.........._..... _ �+ DATE ....------•------••----••••----- FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS TEST H•O1;Es DISco Tr41YIC. Kr Sax 2.0, LE)T 9 /0 /7 77 N SPECTOR PR&PO: WELL EEb a8� `1.,Q9_ E�Ev 6;5 /37 TQ 3 BEDROOM i aT " 3 RESEaevE. CLR P LJ/7W F Sq/U/D LU17f/ S/c_7' 3o a 8.5 /46. dL.6 NO 14,),67f R DYC00Al7 C!T'45.b 3 0 . F.2�iV T f Si Z7� f, : T2F...�f Tom` P20 po 5E17 SE P T/C 5 y5.774-M• COA45 T12 C./G 7`/ A/ SNA 4-Z- TO S. S. G`�v FLOW L GONF02M MA • , GA IDA Y I DE ENV,/29,^,WENTAE. . -- ' s 'EVI,?E s '7-1- 7.7' L-E-A.C.-1 f2ATE � 2 7 N �/h/CN ' P2oPos ,a kE0 Z L jE,9e.R. ,-feF:A��3Q C •Q ' yE.7-A/ .�86lJL.A T/G/V 2. Dl� PC G7 S•7-0.,VE" M:4Nf-�QLE Co✓L�2 L1//yT/-//N /� T� .a2E VEti/T:• OF F' P 201%-e <NF/L T/2L1-7 AAh, 4pC�1S7- ,�0,v _ I. GgOX Nl/A//A, —- nn,w1 , �.a��w% • 4 Djq T .Z- ` " >/T�s� -FtOw�n/E /GLT 4` a�a. ... /o LCgG.U', Kc: ,� .,' M7iy .G'iTGNq. — .�rl.� s 471 SOOT /O MiN / AFOOT T'2. Mi�v i i-�fi P/T /000 6-k000 WAS HEO 1 /NV . QLLD�V s /NVE.eT k�,. p� LILC. E. 57 eT CA PA.G/'T y _ 42 DUiNO S - ©T/G 7A Nam' /O00 r F1L CWATEZT/ra:Y7 /.N1/E T : ; k /NVE eT NO GA28AC�E G,2JND ELEU', BOZ7014 C� � h J. piT :9. Cr 3's k . , Z 6 x .> S� y `s 4] ; - ONLY L01,)ER SE 3.5 OF LEf9CH P'/T �2EFE2 nfC CONSIDERED FOR t D£&ZAL LAN AkSh PerEp7'/G K k. //!1• Af f ►� 15' 3x11 ''/ TANK U/57-.2/BU7'/OA/ 60X o-v7-4—a7 5) AND Z-a.4C.�,�/.VG ,a/7- O TO. 8E Q.- WE/A/F4�E?CED CO.�/C/2ETE, } WT Y� G`4NC.2 T� ST�G�tIGTti/ 3000 .�5/ •�-J/N. t �Yatta .; ST€EL 20000 E A? /O LOAD/wG vVQY n/Or To aE Lo�tTED 'iST€ H- 00 r ,A a DES rGAJ L O�a/AvG /S USe—D. 13 # . , . OF LEAC-H, 'PtT ,. Q�StGi�1E�f TO lM.�i}Pt= �. 1 ,47E A/E,4L77•/ A0z5-c/T f x . �. j Q pP tb11R r.- \ I VENT PIPE (O Least 24 Inches tall) tt Y'y 10' mine from Schedule 40 PVC w/Charcool Odor FA 2-te• olA►�. ACCESS ►tAtwtoLEs ter F �-- I I house to septic tank *NOTE: ALL PIPES ARE TO BE 4` SCHEDULE 40 P.V.C. EXIST. Foundation 5Seepptk conk oovety must be T.O.F. elev. • 100.00 wkNn a in. of Anlehed prods 8 aaa over s.Pno Tank- oe oo Grade aver D-Sox- 07.00 aver 97.0o SECTION A -A - I Rd PROFILE VIED' OF LEACHINC SYSTEM ..� Ile -... . 41 S 0.02 3 HOLE TOP OF SAS 22.75 l.° Acorr� .J (H-20) DIST. BOX 3' Maximum Cover f♦ 10' .0.01 or Greoter f4" to 1 1/2 Washed Gushed Stone INLET l YI T �♦$ '. : .,,�.>. .,� ,I PIPE � ST. 1,000 GAf! 3" of 1/8" - 1/2" Washed Peaatone � ..._ . ,�' !� . ,, .�•./ _ � .. FROM FOUNDATION Kr===S� 32' er foot s ti' .1 SEPTIC TAN II ' 4IS n 20' :J �.. THE ACCESS COVERS FOR THE SEPTIC TANK, = :� H-10 �[ r MN l7O �L,: DISTRIBUTION BOX.ANO LEACHING COMPONENTN � N s SET DEEPER THAN a INCHES BELOW FNISHEDCONCRETE FULL FOUNDA710N - �' - J.6 J.6' - - � - - .•.. •`V'^'•I •• S GRADE SHALL BE RAISED TO WITHIN a OF tin es. N N FINISHED GRADE 00a R A ti > t $ STEEL REINFORCED PRECAST CONCRETE. �Seei IA.M htNeer Qw►Mr•20ef NevlgrgieeTsele+tle*ee ` 'J SYSTEM PROFILE o 0 C3 C) cm C3 0 ----/,p' <>'i PLAN VIEW INSTALL TUf-TITE GAS BAFFLES OR EQUALS c Effective Vidth I l� G C] [� C3 t� O Not to Scale - > > � > D '.STRIPOUT.ALL AROUND 19' 3-24• REMOVABLE COVERS GENERAL NOTES b c 2 Un is Q 8.5' a/2' Separation 0 ELEVATION 6300� 8. ( 1. Contractor is s responsible for Di safe notification e In.ar a/4•-t t/2• '..I L � ( rep g i I compacted stone a6 s • . . ,, µ. , r.:, i Po r••'�•. .:.• '•, and protection of all underground `utilities and pipes. l 25' 3• min- doorance Bottom of Test Has 1 Elevr81.25 n I ,y-fu 2. The septic.tank a distri t{tion box shall be set I I --------------_.__.� Effective Length B• min. Y mh. Wet to outlet INLET -Ll�_ r min ;` level on 6 of 3f4 -1 1p2 atone. d L�„-_t�Twe� ouTl�r 3. Backfill should be clean sand or gravel with no S❑IL ABSORPTION SYSTEM (SAS) _r stones over 3� in size. 5 .• 4. This stem is subject to inspection during installation with _ s system 1 P 9 I NOTE: ALL COMPONENTS MUST HAVE RISERS TO WITHIN 8 BELOW GRADE Note. Remove aotl down 20 mad Bond layer J: replace t 500 C CH 10) LEACHING UNITS / WIGGINS PRECAST (slay. 83.00) & replace with clean coarse sand w/pert. ♦-0 ruin. r L,a,b a.vN by.Carmen E. Shay - Environmental Services, Inc. rate lose than or equal to 2 min./In. before dI after placement Not to Scale �9 5. The contractor shall install this system in accordance • '� .; �, i �. with Title V of the Massachusetts state code, the app oved pion .�. ,.. . ., .. ,. ... .. : ., .,•. .., .• . .. .,.... ..•.. � �-••) and local Regulations. - Note: Certification of Fill Material Required. _ Before and After Placement by Solve Analyses 6. If, during installation the contractor encounters any END-SEC°IRON soil conditions or site conditions that are different 1 CROSS SECTION I from those shown on the soil log or in our design ; installation mu t halt do immediate notification be ' s - Environmental rvicas Inc. made to: Carmen E. Shay Se ' TYPICAL 1000 GALLON SEPTIC TANK y 7. No vehicle'or heavy machine shall drive over the NOT TO SCALE vY machinery ( I - n n . septic system`unless noted as H 20 septic compo e s B. Install Tuf-Tito as baffles or 'e uals on all outlet tee ends. 9 q 9. All Distribution Lines shall be 4 diameter Sch. 40 NS PVC pipes. . fittings II b "-diameter 10. All solid piping, tees & tt ngs shall e 4 tight joints. LOT #8 PERCOLATION TEST schedule ao NSF -PVC pipes with waterg , n I I Water. FrOrr1 Site Date of Percolation Test. 10-17-1977 11. SurroundingProperties are NOT Connected to Mu is p Private Well over 150 FF R - R.S. C.S.E. MUNICIPAL WATER IS AVAILBLE ON EVERGREEN DRIVE. Test Performed By. DOUGLASS GI 0 � j r 'of Health Results Witnessed By. DOUG McINTYRE FOR BARNSTABLE Bea d Excavator: UNKNOWN Percolation Rote: Less Than 2 min. inch 0 168 BELOW GRADE. Test Hole THE PROPERTY LINES ARE APPROXIMATE AND I COMPILED FROM THE SURVEY. PLAN GENERATED BY I, No. 1 I RONALD A GIFFORD OF BARNSTABLE, MA, DATED 11/16/7 s DEPTH SOILS ELEV.j ENTITLED " CERTIFIED PLOT PLAN OF LOT #10 BOXWOOD (DRIVE 0 97.02 BARNSTABLE, MA" AND IS NOT INTENDED TO BE A SURVEY PLOT Loomy Sand PLAN. IT SHOULD BE USED FOR NO PURPOSE OTHER THAN torsi 3/2 I THE SEPTIC SYSTEM INSTALLATION. 0•-10" A 98.15 I Loomy Son ( . +oTR 5/a WETLANDS LOCATED WITHIN A 200' RADIUS ARE SHOWN N PLAN. 10"- 36" 8e 94.00 SILT LOAM I ' to rR 5/4 Note: Remove soil down to el. 83.00 & replace with wE�� 24"-Tee" C' 83.00 ASSESSORS MAP 216 PARCEL 058 clean coarse sand w/pert. rate less than or M PR1vASE ZONING - RESIDENTIAL or equal to 2 min./In. before & after placement p Me°'-Coorae 0\US FR sand (5 FOOT STRIPOUT ALL AROUND AS SHOWN) RP I 2.5 r a/a FLOOD ZONE C 168'-216 Ct 79.00 p I WETLANDS LOCATED WITHIN A 200' RADIUS ARE SHOWN ON PLAN. Y I I LOT #9 -- - � - _- ..._.... Pert #1 �... - Depth to Per 168" to 186„ Per a e c2 min. frith „ cRt / � 4 PVC � LEGEND 1 Not 0 erved ♦ � Groundwater Observed Vent Pipe t „ P / ♦ T ley. 216 - R ADA t . ` BO TTOM 0 F TES HOLE E VICTOR N F � , ADJUSTED H2O Elev. None Required. ..� ♦♦ 8X0 DENOTES PROPOSED I NDEVELOPED LAND . . 'SPOT GRADE ' , / •, •>. ♦ . �C ALL ouTLET FROM THE 1 6 ♦ ♦ PIPES _ .. . �� ♦ . . asTRleunaN sox SHALL BE I 12 CONCREIT COVER 'r .�- •. . .: ♦ ... .('). FOR AT FT. _ � �� �2 DENOTES EXISTING _ ,.. . .�... , SPOT GRADE 94 Q- KNoaouTss Failed •' ,+ / `♦ v • . :: •/ i' �y O p� - - 5 • tz• wuT__ PL PROPERTY LINE ,9 Leach Pit D-� x y♦*,�f // PROPOSED CONTOUR `�` �� / �♦ t70 �Oa tee' 4" SC:M. 40 Tee,/ t75• 97- - - -97 EXISTING CONTOUR g6 Q PLAN SECTION CROSS-SECTION I 0 6 --- DEEP TEST HOLE & g TEST HOLE 1t 3 HOLE DISTRIBUTION BOA - H-10 LOADING ►N ELEV - 97.00 NOT TO SCALE PERCOLATION TEST LOCATION o 0rO FENCE j Desi n Calculations ; O �/ LOT #12 g EXIST, l000 gale ` UNDEVELOPED LAND Garbage Grinder: No to 220 Goi./Day (330 Gal./Day Min. per Title V) - PRIVATE DRINKING WATER WELL Number of Bedrooms: 2 Equivalent Septic Tank ISTINC --- // / / / Leachingonk Capacity2Pxo330 W./Day Gal./May6t60 Minimum USE r ,5001nGAL.Per SeTitle ti,, Tank. REVISIONS, EX I �. P / Y P 2 BEDROOM ` i ,' SOIL ABSORPTION AREA: Using percolattion rate of <2 min./inch HOUSE , � ,' Bottom Area: 0.74 gal/sq. ft. x .30Dsq. ft: 222.00 ,gallons NO. DATE: DEFINITION Sidewall Area: 0.74 gal./sq. ft. x 148 sq. ft. - 109.50 gallons Providing: - 331.50 gallor s Use: (2) PRECAST 500-C UNITS, HAVINJG A 2' EFFECTIVE DEPTH, ?Q, 12 .5' / /' 1 `O \� 19 �'� TO BE USED WITH 3.5' OF WASHED STONE ON THE SIDES AND O' /� /' E ► 6' ,' 3' OF WASHED STONE ON THE ENDS AND 2 FEET IN BETWEEN 2 UNITS. i Gravel I DRIVEWAY I \ / P 0 S E D LOT #10 ` 1 1i � ; �.'� //'� � i P1 \ .,.� � I 16,005 Square Feet +, tt t PREPARED FOR . �� !SUBSURFACE SEWAGE DISPOSAL SYST M � �� ,'' UNDEVELOPED LAND PROJECT BENCH MARK , - - I I � OF TOP OF FOUNDATION � ELEV. = 100.00 Assumed �� MS . BAR BARA WHITE #56 BOXWOOD DRIVE E 56 BOXWOOD DIRIVE I WEST BARNSTABLE, MA . . W \ , tT \�♦ { i'/ �� N/F MARION RANIGAN o• ,, ��,� - 00 OF PREPARED BY: UNDEVELOPED LAND �y ��i�y w WEST BARN STAB LE,1 MA `�H afgS ` CARM�'N E. SHA Y E'NVIR0IV MENTAL SE'RVICE'S INC. 34 THATCHERS LANE �o� /�' �' EAST FALMOUTH, MA 02536 A, I. I NITAR LOCAL UPGRADE VARIANCES REQUESTED: ' TEL FAX 508-548-0796 O 1. Request.a varaiance to reduce the distance from the onslte private well / ' from 150 feet from-the SAS to 121.5 feet. SCAT-E: 1 ..=20' DRAWN BY: CES DATE: APRIL 9, 2004 PROJECT#SD-555 FILENAME: SD555PP.DWG SHEET 1 OF 1' __