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HomeMy WebLinkAbout0030 BURSLEY PATH - Health 30 B irsley Path,West Barnstable A= 089-009 0 l r ©99- aa9 c Commonwealth of Massachusetts Title 5 Official Inspection Form „} Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u 30 Bursley Path r" Property Address CA t4 Krista Kerr Owner Owner's Name ? information is required for every West Barnstable // Ma 02668 9-25-18 page. City/Town State Zip Code Date of Inspection ,_ Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. Inspector Information 5/ on the computer, Brett Hickey use only the tab key to move your Name of Inspector cursor-do not B&B Excavation use the return Company Name key. 374 Route 130 y Company Address Sandwich Ma 02563 City/Town State Zip Code (508)477-0653 S113747 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the system: 1. ❑■ Passes z 2. . ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails o,a��ty ����m Brett Hickey �^ ����.a . •��s 9-25-18 t Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of ' 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate '. regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future.under the same or different conditions of use. t5insp.doc-rev.7/26/2018 - - Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts �n p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 30 Bursley Path Property Address Krista Kerr Owner Owner's Name information is West Barnstable Ma 02668 9-25-18 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: On I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The system was in working order at the time of inspection. 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined,"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Y ,F Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. f ❑ Y ❑ N ❑ ND (Explain below): ,. • Y t5insp.doc•rev.7/26/2018 - Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 16 t Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 30 Bursley Path V Property Address Krista Kerr Owner Owner's Name information is West Barnstable Ma 02668 9-25-18 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 t l c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 30 Bursley Path Property Address Krista Kerr Owner Owner's Name information is West Barnstable Ma 02668 9-25-18 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water ' supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: r 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ a Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool El El due or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18 Commonwealth of Massachusetts �. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments I; 30 Bursley Path v Property Address Krista Kerr Owner Owner's Name information is West Barnstable Ma 02668 9-25-18 required for every page. City/Town State Zip Code Date of Inspection C. Inspection.Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ Q Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ a Liquid depth in cesspool is less than 6" below invert or available volume is less than '/z day flow ❑ a Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ El Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ El, Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ a Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ El Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ El Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ❑ The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ El 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. t 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section CA. Yes No } ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well t5insp.doc•rev.7/26/2016 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 2- i 0 c Commonwealth of Massachusetts �d Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments L 30 Bursley Path v Property Address Krista Kerr Owner Owner's Name information is West Barnstable Ma 02668 9-25-18 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered"yes"to any question in Section C.5 the system is considered a significant threat, or answered"yes"to any question in Section CA above the large system has failed.The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes" or"no"for each of the following for all inspections: Yes No El ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ E Were any of the system components pumped out in the previous two weeks? El ❑ Has the system received normal flows in the previous two week period? ❑ 0 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 ❑ NA available note as N/A) ❑ El Was the facility or dwelling inspected for signs of sewage back up? Q ❑ Was the site inspected for signs of break out? Fx� ❑ Were all system components, excluding the SAS, located on site? El ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ❑ 0 Existing information. For example, a plan at the Board of Health. O ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts _ �d Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r 30 Bursley Path �V Property Address Krista Kerr Owner Owner's Name information is west Barnstable Ma 02668 9-25-18 required for every page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: no design plans 4 Number of bedrooms(design): Number of bedrooms(actual): NA DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): Description: No design plans were available at the Board of Health. 2 Number of current residents: Does residence have a garbage grinder? ❑ Yes No Does residence have a water treatment unit? ❑ Yes No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes 0 No information in this report.) Laundry system inspected? ❑ Yes 0 No Seasonaluse? ' ❑ Yes [E No See below Water meter readings, if available(last 2 years usage(gpd)): Detail ***WELL WATER*** Sump pump? ❑■ Yes ❑ No current Last date of occupancy: Date t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 ' s Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments f; 30 Bursley Path Property Address Krista Kerr Owner Owner's Name information is west Barnstable Ma 02668 9-25-18 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: NA Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: _ Owner- last pumped 1 year ago Source of information: Was system pumped as part of the inspection? ❑ Yes M No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18 , 11i I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 30 Bursley Path Property Address Krista Kerr Owner Owner's Name information is West Barnstable Ma 02668 9-25-18 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: E Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ .Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: 1989 per town Were sewage odors detected when arriving at the site? ❑ Yes H No 5. Building Sewer(locate on site plan): 11611 Depth below grade: feet Material of construction: ❑ cast iron ❑■ 40 PVC ❑other(explain): >100 from well to SAS Distance from private water supply well or suction line: feet { Comments(on condition of joints, venting, evidence of leakage, etc.): .. s' t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 l cam, Commonwealth of Massachusetts �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 30 Bursley Path u Property Address Krista Kerr Owner Owner's Name information is West Barnstable Ma 02668 9-25-18 required for every page. City/Town State Zip Code Date of Inspection. D. System Information (cont.) 6. Septic Tank(locate on site plan): 611 Depth below grade: feet Material of construction: X concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000gallon — 6" Sludge depth: 30" Distance from top of sludge to bottom of outlet tee or baffle On Scum thickness — NS Distance from top of scum to top of outlet tee or baffle NS Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? measured Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): The tank was in working order at the time of inspection. The tank is not in need of pumping at this time but should be pumped every two years for maintenance. t5insp.cloc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 c Commonwealth of Massachusetts �m Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 30 Bursley Path Property Address Krista Kerr Owner Owner's Name information is West Barnstable Ma 02668 9-25-18 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap(locate on site plan): NA Depth below grade: feet Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8.., Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): _ -Depth below grade: NA Material of construction: El concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: . gallons per day t5insp.doc•rev.7/26Q018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 j Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 30 Bursley Path u Property Address Krista Kerr Owner Owner's Name information is West Barnstable Ma 02668 9-25-18 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): o„ Depth of liquid level above outlet invert Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): The d-box was in working order at the time of inspection. i t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts �= Title 5 Official Inspection Form r Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 30 Bursley Path u Property Address Krista Kerr Owner Owner's Name information is West Barnstable Ma 02668 9-25-18 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑• No" Alarms in working order: ❑ Yes F!] No' Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): NA * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: (2) 61X61 El leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: overflow cesspool number: , ❑ innovative/alternative system Type/name of technology: ' t -t5insp.doc•rev.`T/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18 Commonwealth of Massachusetts �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ` 30 Bursley Path Property Address Krista Kerr Owner Owner's Name information is west Barnstable Ma 02668 9-25-18 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) - Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): The leaching was in working order. Both pits were half full at time of inspection. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration NA Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction ., Indication of groundwater inflow ❑ Yes ❑ No Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 c Commonwealth of Massachusetts �v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 30 Bursley Path Property Address Krista Kerr Owner Owner's Name information is West Barnstable Ma 02668 9-25-18 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): NA Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 c� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 30 Bursley Path v� Property Address Krista Kerr Owner Owner's Name information is West Barnstable ' Ma 02668 9-25-18 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑■ hand-sketch in the area below ❑ drawing attached separately Asbuilt Ground water profile Al-22' Bl-39' W V A2.26' B2.42' r A3.33' B3.47' 3' 9' >14' 1 pool O „ 3 a 0 Ground water _ t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 t • a'4 w L c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 30 Bursley Path V Property Address Krista Kerr Owner Owner's Name information is West Barnstable Ma 02668 9-25-18 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ■❑ Check Slope Q Surface water 0 Check cellar Shallow wells Estimated depth to high ground water: NoGW@14'feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) M Accessed USGS database -explain: USGS Topo maps You must describe how you established the high ground water elevation: Topo maps show the property to sit >14' above ground water. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 30 Bursley Path Property Address Krista Kerr Owner Owner's Name information is West Barnstable Ma 02668 9-25-18 . required for every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ❑� A. Inspector Information: Complete all fields in this section. ■� B. Certification: Signed& Dated and 1, 2, 3, or 4 checked C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4(Failure Criteria)and 6(Checklist)completed ❑■ D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 _Dopar- went of Environmental Management/Division of Water Resources }< r WATER WELL COMPLETION REPORT WELL L CATION GEOGRAPHIC DESCRIPTION Address _ O N S E W of (/earl (circle) 1 City/Town PZ J0'#& Well owner �. (road) Address N S E W of TX in tenths) ll (circle) Board of Health permit: yes no ❑ intersect. w/ 1 G (roa 1 WELL USE. / WELL DATA Domestic jj Public❑ Industrial ❑ Total well depth ft. Monitoring❑ Other Depth to bedrock ft. Method drilled 12 Water-bearing rock/unconsolidated material: Date drilled Description Water-bearing zones: CASING T ��G 11 From—To Type . r� 2) From To ' Lengthx_ft. Dia(I.D.) in.. 3) From To i Length into bedrock ft. Gravel pack well: dia. Protective well seal: Screen: dia. Grout-❑ Other/4&0 S16t*/2_length from to PUMP TEST Static water level below land surface. !Zd ft. Date Drawdown_ fI. after pu,mping_4( . hr. min.a gpm How measured t-A 91Recovery ZIPC ft. af ter hr min ,r o. I. N COMMENTS >- . n f FORMATIONS, C LOG o Q . III - ?},°_'•: G +'..;. Materials From To< Driller d. y Mass.Registration,41 Flr I � T4 AddressAK k.1 t t Clty/Town r ... "ts<r �g .r r -Signature of.supervrsrn .registered well,dpller Please print frrmty BOARD TH QF< HEAL COPY r ,fir 4 L�I:., --��"�,a+�,"a�.i r 3','.:'A�`2a.'�•�,;rw• '�fia'Ge��tir,'Y.' " •e� �;;YJ�w �.. ._� t�� �" i�r..&�`x �'. F Commonwealth of MossachusettS Executive Office of Environmental Affairs Deportment of Environmental Protection Wllllam F.Weld Trudy Coxe Governor seem" Arpao Paul Colluccl David S.Struhs u.C%o.rmr 12 mssiorw SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A U,RS Le y CERTIFICATION �y Property Address 3O �" _ `✓G �'�. Address of Owner. y�or St Date of Inspection: 2-2p- �'(� (If different) �'tiaQry ,l Name of Inspector. y�'I a2..�. Ffs�� c99& = Company Name,Address and Telephone Number. 'g 3 CERTIFICA ION 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: asses _ Conditionally Passes Needs Further Evaluation By the Local Approving Authority _ F ' Inspector's Signature: /G -' �� Date: The System Inspector shall bmit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer,if applicable and the approving authority. , INSPECTION SUMMARY: Check A,B, C,or D: tiIA] SYS PASSES: 4 I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B] SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system,upon completion of the replacement or repair,passes inspection. Indicate yes,no,or not determined(Y,N,or ND). Describe basis of determination in all instances. If"not determined",explain why not) The septic tank is metal, cracked,structurally unsound,shows substantial infiltration or exfultration,.or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a ponforming septic tank as approved by the Board of health. (revised 11/03/95) 1 One Winter Street a Boston,Massachusetts 02106 • FAX(617)5WI049 • Telephone(617)292-WW ice,Primed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Owner. Date of Inspection: B)SYSTEM CONDITIONALLY PASSES (continued) 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 ins ion if(with approval of the Board of Health): broken pipe(&)are replaced _ obstruction is removed distribution bolt is levelled or replaced The system required p ping more than four times a year due broken or obstructed pipe(s). The system will pass inspection if(with app of the Board of Health): broken pipe(s)are replaced ruction is removed C] FURTHER EVALUATION IS REQUIRED BY BO OF HEALTH: Conditions exist which require further ev' do 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 BO OF HEALTH ETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTEC THE PUBLIC H TH AND SAFETY AND THE ENVIRONMENT: _ Cesspool or privy is wit 50 feet of a surface water Cesspool or privy is hin 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL S THE BOARD OF HEALTH (AND UBLIC WATER SUPPLIER,IF APPROPRIATE) DETERMINES THAT E SYSTEM IS FUNCTIONING IN A NER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE RONMENT: The syste has a septic tank and soil absorption system and is wi 100 feet to a surface water supply or tributary to a surface ter supply. The m has a septic tank and soil absorption system and is within a Zone I of a public water supply well. The m has a septic tank and soil absorption system and is within 50 feet of a private water supply well. The m has a septic tank and soil absorption system and is less than 100 feet t 50 feet or more from a private water SUP y well,unless a well water analysis for coliform bacteria and volatile o - 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. 3) OTHER (revised 11/03/95) 2 } SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Owner. Date of Inspection: D1 SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage to facility or system component due to an overloaded or clogged SAS or cesspool. _ Discharge or ponding o fTluent to the surface of the ground or surface, �ter,due to an overloaded or clogged SAS or cesspool. � Static liquid level in the distrib tion box above cutletinvert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less t 6"below invert or available volume is less than 1/2 day flow. Requite pumping more than 4 times the'last year NOT due to clogged or obstructed pipe(s). Number of times pumped Any portion of the Soil Absorptio ystem; spool or privy is below the high groundwater elevation. Any portion of a cesspool or vy is within 1 0 feet of a surface water supply or tributary to a surface water supply. _ Any portion of a cesspoo or privy is within a Zo e I of a public well. Any portion of a cess I or privy is within 50 feet a private water supply well. Any portion of a pool or privy is less than 100 feet t greater than 50 feet from a private water supply well with no acceptable wate quality analysis. If the well has been yzed to be acceptable,attach copy of well water analysis for eoliform bacte". volatile organic compounds,ammonia nit gen and nitrate nitrogen. E)LARGE SYSTEM FAI The following enteria apply to large systems in addition to the criteria above: The system/eves a facility with a design flow of 10,000 gpd or greater(Large S m)and the system is a significant threat to public health andsafety and.the environment because one or more of the following conditi exist: the system is within 400 feet of a surface drinking water supply _ the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area(IWPA)or a mapped Zone Hof a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.. (revised 11/03/95) 3 c SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 3c� Owner. Date of Inspection: �-E1 Check if the following have been done: "'Pumping information was requested of the owner,occupant, and Board of Health. one 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 sywtem recently or as part of this inspection. v _As built plans have been obtained and examined. Note if they are not available with N/A. .L—'The facility or dwelling was inspected for signs of sewage back-up. ✓The system does not receive non-sanitary or industrial waste flow !_/The site was inspected for signs of breakout. `-All system components,excluding the Soil Absorption System,have been located on the site. The septic tank manholes were uncovered, opened,and the interior of the septic tank was inspected for condition of baffles or material of construction,dimensions, depth of liquid,depth of sludge,depth of scum. Y ' ed based on information or The size and location of the Soil Absorption System on the site has been determined eastu►g approximated by non-intrusive methods. _V/Th_e facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub- Surface Disposal System. revised 11 03 95) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C r - - SYSTEM INFORMATION Property Address: Owner. Date of Inspection: FLOW CONDITIONS RESIDENTIAL• Design flow: ona Number of bedrooms; Number of current residents:-1-- Garbage grinder(yes or no): _ Laundry connected to system(yes or no): Seasonal use(yes or no):.1dz11P Water meter readings, if available: - C� Last date of occupancy COMMERCIAL/INDUSTRIAL. Type of establishment: Design flow: .....gaDons/day r Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yea or no)_ Non4anitary waste discharged to the Title 5 system: s or no)_ -` Water meter readings,if available: Last date of occupancy: OTHER (Describe). Last date of oceupan y� GENERAL INFORMATION PUMPING RECORDS and source of information: System pumped as part of inspection: (yes or no),d_jQ If yes,volume pumped: gallons Reason for um P PinB: - .. TYPE OF SYSTEM �beptic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes,attach previous inspection records,if any) Other(explain) APPROXIMATE AGE of all components,date installed(if known)and source of information: /F, Sewage odors detected when arriving at the site: (yes or no)w (revised 11/03/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C - SYSTEM INFORMATION (continued)' Property Address: & y P`�" - CU Owner. C� Date of Inspection: p —� SEPTIC TANK: (locate on site plan) Depth below grade: Material of construction: erete—metal—FRP—other(e:plain) Dimeasions- Sludge depth:_ G' Distance from top of sludge to bottom of outlet tee or baffle: s Scum thickness: Distance from top of scum to top of outlet tee or baffle: 3 0-i Distance from bottom of scum to bottom of outlet tee or baffle: 7 Comments: (recommendation for pumping, condition of inlet an outlet tees or baffles, depth o liquid level in is on to outlet invert,structural gri evidence of leakage, etc•) " GREASE TRAP:— (locate on site plan) Depth below grade: Material of construction: —concrete_metal— —other( p}uin) Dimensions: Scum thickness: Distance from top of scum to top of et tee or baffle: Distance from bottom of scum ttom of outlet tee or baffle: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity, evidence of leakage, etc.) (revised 11/03/95) .6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address 30 'B u p Owner. Date of Inspection; C: TIGHT OR HOLDING TANK_ (lo_c-a-t`e on site plan) (l Depth below grade: m f • Material of construction:_concrete_metal_F other(e=plain) - Dimensions: Capacity: ¢allons Design flow: ¢allona/day ' Alarm level: Comments: (condition of inlet tee,condition of and float switches,etc.) DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert: Comments: ,» r (note if level and distribution is eq ,evidence of solids c r-yover,eviden of leakage into o�out box,etc.) l ✓ i PUMP CHAMBER (locate on site plan) Pumps in working order:(yes or no) Comments: (note condition of pump chamber,co of pumps and a etc.) (revised 11/03/95) 7 e SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM t i PART C SYSTEM INFORMATION(continued) (� Property Address: 3 a't� /"a"" `✓ Owner. 9 Date of Inspection: Z- 'D-v — SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, if possible;excavation not required,but may be approximated by non-intrusive methods) If not determined to be present,explain: leaching pits, number leaching chambers,number:_ leaching galleries,number: leaching trenches, number,length: leaching fields,number, dimensions: overflow cesspool,number: Comments- (note condition of soil,signs of hydraulic fa'ure evel of ponding,condition of ve tion,etc.) / 1-1 , CESSPOOLS:_ (locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater: inflow(cesspool must be as part of inspection) Comments: (note condition of soil, signs of hydraulic fail vel of ponding, condition of vegetation,etc.) PRIVY:_ (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments:(note n of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.) (revised 11/03/95) 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address:' jv Owner: - Date,of Inspection: ^ SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' W �Y to� _ 77- DEPTH TO GROUNDWATER Depth to groundwater: � feet method of determination or approximation; (revised 8/15/9s) Ny 3a,1'a�'c *1[•r +� r. 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F. ,41 a;'el' .h"•7:•- a�F; - ,•r e= ..i•,i, !,,rt •'•i, r"F#j,,iiEuh.. ,t`� .ri'.Ct .. ,\ `ti A•.a,r- :'�. .b e.r \� - •_-ih,e �yr t�.3,;bitf. _S;,!,'..}- ''�'-,.-s••r.au n4•r k.: _4.f R 'ra, -t::} avaii��:L`..-.,...,`,. fi ap, :7 ue a •u. - J �--r .. _ ' --- --ate..- -' ` . ��l `� 5�.. ..T - y 17"- ....--a.m�-' ----ram !! . . . . - 1. .J 1 1 mil- e •:':yi' 1�( i(oti+ Y "•�i .11 ,i.V'-'% .i,' t�5•r M;.tc-' ,'9.•.0 1T��t^` �/� .kCr J:3�gym.• Y•Sa :`�' .q.i,�1• ItFi;�, 1�! " rah. •fi i ` . `„`^•ii! ',� vas_q. U,, ti f� 'f :y� r :S' 1 +t r `.�i,I. ':r't.,rt•,..tfAr! (( ^r•;,,•yli�`'��'r�" ,.�+ ',{ .t.ta'1�� tid:,�T:^r ;'.. `}.�: u�d a,r• :1•" I r; hJy >'!.'1 ` IL+Jf X,,fajl c aX, d.� ^�sF.(,. )�?}:9 sh.•�+;;f ,y.. ♦-�...b., cti - 5'• a: ••i :b.7:Jit.•. I1: :1�]r :,:y. .•Fit. R r l / 3 s e .II O 1 14 11-4 _ r` - ( TtS a � : 1- Li 4,1 3 t"l ti10 .1! •1 V :r r` t> r L l S �4 r- Yr�a.�;:.c:L:r,•::2:-a;•:''.'- + i •I- C)p !/,/ o TOWN O BARNSTABLE LOC *C14 SEWAGE # F5 "A Idfr'i SJ.X 20 VILLAGE U-). ci t( e ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. C/I LA &•e 1,5rofttA 3 S ! Zs-//i SEPTIC TANK CAPACITY /f© CD LEACHING FACILITY:(type) 02(sue) NO. OF BEDROOMS % PRIVATE WELL OR PUBLIC WATER r BUILDER OR OWNER 1- DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No f � � ����' �ol / �f �,U�' f C� Y 1� . �� f � `" /fir � I /�jf Uv5 2 F�s....7c:J .....:.... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ...................... ....................OF...................................... Appliration for Dhgpogal Works Tomitrnr#ion Frrmit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual sposal System at: � i°l_ ce d A-1- elaezz-� Y .... .CST .. .............w ..........................................=..... _Location-Address or Lot No. .......... s; 1.0 1 c 5 C t io", S C,r 1)oa"o W .... >n.-Z.A. ...................•-------..._..._ ......------ ._...y..-----l----Y'- .........--`� Owner Address W Installer Address Type of Building Size Lot-------------------•--------Sq. feet --� Dwelling_—No.of), Bedrooms..............fY.........................Expansion Attic ( l/j Garbage Grinder ( ) P4 Other—Type of, Building of persons---------------------------- Showers (A,) — Cafeteria ( ) a � Other fixtures ........ ---••--------------................................................................................................ W Design Flow.___._..G/` ).........................gallons per person per day. Total daily flow......__�.gb........................gallons. WSeptic Tank—Liquid capacity..LSGPgallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No. ........ .......... Width.....(............. Total Length---4��........ Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) ~' Percolation Test Results Performed by.......................................................................... Date....................................... Test Pit No. l.4_2,.....minutes per inch Depth of Test Pit.................... Depth to ground water........................ GL; Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ M ..................................------•----•---•----------------------------------------------•---.......-------•••----••-•............•---•--•-••-•----- 0 Description of Soil..........$L!S.� ........ .......................................... --------------------------•---------.......-•---••-----------•--•-••-----•-----. W VNature 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 iITLi� 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been iss ed by he oard of Health. Signed••.._ -••• ���---•-• �rl!._... •-•-----••-----••-. S ` Date Application Approved By-••--------... ----•-•. ----------------•---•--•--------------- Date Application Disapproved for the following reasons:-------•--...-------•---•------•------•--••------••----•---•---------------•-----.--•-------................... .•• •••••••-•--•••-•-•-•••••---••---•••••-•-••••-•••••-•••••--••-•---•--••-•- ----•-------•--••-•--•-----------•-•-• ....................... Date Permit No.......Y....S.3.�--------------••--••- Issued ..-.... Date r � ~ j................ { .� . THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .................. ..... ................O F........................................------ Appliration for Diopooal Works Tonotrurtion runfit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: �, ............................................c, ' ? . ....�?�...... ................... .......•----...-•-•----...........------•-- ---........------------......---•-------- Location Address or Lot No. l _ l LNt '-k � � lv [r C1 l� e1: n�,.n 91 nA�Cr• { �fit� 4� n ............... ....... r_..._.., ._' _ ....__...--....__.........._... .....'____..._......._._....__...._.._....___"' .....=._.__. ......_... ......_._..._. Owner Address W Installer Address Type of Building Size Lot............................Sq feet Dwelling-No. of Bedrooms..............�/._....._........._.......Expansion Attic ( fi') Garbage Grinder ( ) Other—Type of Building No. of persons............................ Showers (,;7,) — Cafeteria ( ) QI Other fixtures ........ E :-•�"..'' �=-•----• -••-------------------••-••---••---••-•-•••--- Q W Design Flow_.__.._.��`�r_13.........................gallons per person per day. Total daily flow_._____.L_ -�........................gallons. WSeptic Tank—Liquid*capacity.._.:�_�_:gallons Length................ Width................ Diameter---------------- Depth................ I 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 ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1.4..)......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_--_--_.___-____--_____. .,.-••-••....... ........................••----•--------••••-••••-••--....--••••-•-._.......-------•----•'•--•-•-••-----------••............•--------.•••... O Description of Soil........... = -•----. f r.-,.;r, x4 .......................................•....._--------•--•-----•-•-----------------•---••-•••...--- U ........................•-.....________......------...._..____..._.......___._.___._............._......_______....------•........__....-----_...__------------••-----•---••••••--•...._......----------- W ........................................................................................................................................................................................................ U Nature of Repairs or Alterations Answer when applicable................................................................................................ ............................................................-.........---------------•-•-•-----------------•----------------------------------------------------------------------------------.....---- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has%,been inued bey rd of health. Signed---'.......!-........................' } �r,+ /�S �.) u Date Application Approved By.............. ..............� _.�-_.__- ----�_ Date Application Disapproved for the following reasons:-----•---------------------------------•-----------------------------------------------------------------....... ------------------------------------•----•-----------•--------------------•------•---....------------------------------•--•-----•--•------------------•-------------------...•-------•---•------••--•--- Date PermitNo. � - 3 ...................•... Issued-------------------------------------------------------- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........:Z ...............OF..... pr.—. (............................................. 0.1rdifirFate of T-impliFanrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (7 ) or Repaired ( ) b n Installer _/J has been installed in accordance with the provisions of '1'?TIZ 5 of-The State Sanitary Code as described in the application for Disposal Works Construction Permit No._...e.1_.:--_5a_._...._. dated_-----_________________________________________ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATee.............................................................._..._........... Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ��•`D '2.r� ...............�.61:I/..............OF.....1..� _.(,r -A.. ..................................................' No. ----•='........ FEE.,-----•-2............ orko �ono�raar�ion rranit Permissionis hereby granted.............................................................................................................................................. N`to Construct (` or Repair ( ) an Individual Sewage Dispose y F� Disposal System t at No......... � ........tCL*: !J ^ct....�a ? 1 = .... ) `- . \J Street �✓ I as shown the. p� ' tion for Disposal Works Construction Permit o. r aged _..L""........................... -/ � •---•------------•------------------------ .............................................................. Board of Health DATE................................................................................. FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS OFFICE LABORATORY 1498 HIGH STREET 176 PLYMOUTH STREET BRIDGEWATER, MA 02324 BRIDGEWATER, MA 02324 OLIVEIRA ENVIRONMENTAL LABORATORIES, INC. FOOD- DAIRY PRODUCTS-WATER-WASTEWATER CHEMICAL&BACTERIOLOGICAL ANALYSES (508)697-2650 October 10, 1989 L. Wile & Son Drilling Co. 11 Annasnappitt Drive Plympton, Mass. 02367 Source: Well Water - Drilled Well - 4 inch - PVC Well - 80 feet deep - producing 10 gals/min. Located on the property of Mr. Michael Danzillo - Lot 36-30 - Bursley Path - West Barnstable, Mass. Coliform Count /100 ml @ 35 C 0 Membrane Filter S.P.C./ml @35C 240 Color (APC units) 25.0 Sediment none Turbidity (NTU) 30.0 Odor none Taste satisfactory pH 6.50 Specific Conductance 65.0 micromhos/cm mg /liter Total Alkalinity (CaCO,) 10.0 Free CO, 6.10 Total Hardness (CACO,) 14.0 Calcium (Ca► 4.00 Magnesium (Mg) 0.98 Sodium (Na) 8.60 Potassium (K) 0.87 Total Iron (Fe) 0.23 Manganese (Mn) L 0.01 Silica (SiO,) 11.5 Sulfate (SOO 8.00 Chloride (CI) 12.5 Nitrogen - Ammonia 0.02 Nitrogen - Nitrite 0.005 Nitrogen - Nitrate L 0.10 Copper (Cu) _ L = less than On site collection made by L. Wile — 10/6/89 at 4:00 P.M. Sample delivered to laboratory by Mr. L. Wile — 10/6/89 at 5:30 P.M. Bacteriologically, this well water is of a satisfactory sanitary standard and is suitable for drinking and domestic purposes. Chemically, this well water meets the standards for all of the chemicals tested. o � Director } The Standard Plate Count indicated the general bacterial population of the well at the time of collection. Coliform Group Bacteria: Significance The coliform group bacteria includes organisms found in the intestinal tracts of warm blooded animals, birds, decaying organic matter(hay, leaves, wood, etc.), the top 2 to 3 feet of the soil, lakes, ponds, brooks, rivers, drainage and types of vegetation. Because the organisms can cause some illness; because the presence of coliform organisms in the water suggests that other more harmful organisms may be present, water containing one or more coliform group bacteria per 100 ml of sample should not be used for drinking or cooking purposes unless boiled 5 minutes or disinfected by other means. This bacteria is of animal origin (intestinal tract)and may be considered as closely associated with disease causing organisms.On this factor, none should be present. Color. — APC Units- Ground water ought to be practically free from color. For attractive water - color should not exceed 15 units. Turbidity — NT Units- Recommended limit not to exceed 5 units. Odor Er Taste — For water to be of high quality, the water should be odor free and taste good. pH — The pH value defines the concentration of free hydrogen ions in solution. Expressed on a scale extending from 0 or very acid to 14 or very alkaline with 7.0 being neutral. Specific Conductance — Conductivity is a good criterion for measuring the degree of mineralization and assessing the affect of diverse ions on chemical equilibria. Total Alkalinity — The alkalinity of this water represents its content of carbonates and bicarbonates. Free Carbon Dioxide — Well water having a low pH and a Free CO, level in excess of 50. mg/I will be corrosive to iron, bronze, brass and copper tubing and fittings. Total Hardness — Standard not to exceed 50. mg/l. Waters having a hardness level of 50 to 100 are in the medium hardness range, over 100 very hard. Calcium -- Calcium contributes to the total hardness of water.Appreciable amounts of calcium salts break down on heating and form scale in boilers, pipes and cooking utensils. Magnesium — Magnesium is a common constituent of natural water. Magnesium and calcium ions are principal contributors to water hard- ness. Concentrations in excess of 125 mg/I can exert a cathartic and diuretic action. Sodium — Recommended limit not to exceed 20 mg/l. Potassium — Potassium concentrations in drinking water seldom exceed 20. mg/I. Total Iron — Standard not to exceed 0.3 mg/l. Manganese — Standard not to exceed 0.05 mg/l.The principal reason for limiting the concentration of manganese is to reduce esthetic and economic problems. Silica — Silica content of natural water is most commonly in the 1 to 30 mg/I. Silica in water is undesirable because it forms difficult to remove silica scales. Sulfates — Standard not to exceed 250 mg/I. Chloride — Standard not to exceed 250 mg/l. Nitrogen — Ammonia is present in variable concentrations in many surface and ground waters. Its occurrence in ground water is generally a result of natural reduction processes. Nitrogen ' Nitrite — Nitrite in water poses a health hazard, but fortunately seldom occurs in high concentrations. Waters with a nitrogen - nitrite concentration over 1 mg/I should not be used for infant feeding. Nitrogen - Nitrate — Standard not to exceed 10. mg/I. Nitrate, in high concentrations can and do cause methemoglobinemia or so-called nitrate poisoning in infants. Water with 10 or more mg/I of nitrate is unsatisfactory and is not considered safe for drinking or cook- ing. It is especially dangerous to children and should never be used in infant formulas. J Copper — Standard not to exceed 1.0 mg/I. u . OFFICE LABORATORY 1498 HIGH STREET 176 PLYMOUTH STREET BRIDGEWATER, MA 0=4 BRIDGEWATER, MA 02324 OLIVEIRA ENVIRONMENTAL LABORATORIES, INC. FOOD-DAIRY PRODUCTS-WATER-WASTEWATER CHEMICAL&BACTERIOLOGICAL ANALYSES (508)697-2650 October 17, 1989 L. Wile & Son Drilling Co. 11 Annasnappitt Drive Plympton, Mass. 02367 Source: Well Water - Drilled Well - 4 inch PVC Well - 80 feet deep Located on the property of Mr. Michael Danzillo - Lot 36-30 - Bursley Path - West Barnstable, Mass. Analysis Number 612 EPA Method 503.1/Volatile Aromatic Compound _ Conc.* MDL* Benzene ND 0.10 Trichloroethene ND 0.10 Toluene ND 0.10 Tetrachloroethene ND 0.10, Ethylbenzene ND 0.10 p-Xylene ND 0.50 Chlorobenzene ND 0.10 m-Xylene ND 0.50 o-Xylene ND 0.50 Isopropylbenzene ND 0.10 Styrene ND 0.10 n-Propylbenzene ND 0.10 tert-Butylbenzene ND 0.10 2-Chlorotoulene ND 0.10 4-Chlorotoluene ND 0.10 Bromobenzene ND 0.50 sec-Butylbenzene ND 0.10 1,3,5-Trimethylbenzene ND 0.10 4-Isopropyltoluene ND 0.10 1,2,4-Trimethylbenzene ND 0.10 1,4-Dichlorobenzene ND 0.50 1,3-Dichlorobenzene ND 0.50 a } ' OFFICE LABORATORY 1498 HIGH STREET 176 PLYMOUTH STREET BRIDGEWATER, MA 02324 BRIDGEWATER, MA OM24 OLIVEIRA ENVIRONMENTAL LABORATORIES, INC. FOOD- DAIRY PRODUCTS-WATER-WASTEWATER CHEMICAL&BACTERIOLOGICAL ANALYSES (508)697-2650 page 2 Compound Conc.* MDL* n-Butylbenzene ND 0.10 1,2-Dichlorobenzene ND 0.50 Hexachlorobutadiene ND 0.10 1,2,4-Trichlorobenzene ND 0.10 Naphthalene ND 0.50 1,2,3-Trichlorobenzene ND 0.10 Notes: ND = Below minimum detectable level (MDL) * = ug/l Tested by Lab #MA022 Sample collected by Mr. L. Wile - 10/12/89 at 4:00 P.M. Sample delivered to laboratory by Mr. L. Wile - 10/13/89 at 7:30 A.M. Director r w-d No.W -,I---- -- F e- -------------- BOARD OF HEALTH TOWN OF BARNSTABLE . Application for Melt Con5tructionPermit W1 8; App'cation is here b made fo, a permit to Construct (Alter ( ), or Repair ( )an individual Well at: .411C/ b_ ---�-fit _-------- ---_-_- - --- - - - ocation — Address Assessors Map and Parcel Owne A ress -_ r -- )) j��iIke---- ------------------- -- Z�7--- Installer — Dril INI/ - Address Type of Building g Dwelling--1- ---------------------------------- Other - Type of Building-----------------------—---------- No. of Persons--- Type of Well----------��-L.�---- `�'---- ---- -- Capacity—----------------_----___— Purpose of Well , �'1� --— ----- — - Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation — The undersigned further agrees not to place the well in operation until Certificate of Compliance as been issued by the Board of Health. Signed— -- - -=- --- - --- -- toe ' Application Approved By--------- -------- --- - '-------------- ---------_- — -- date 'Application Disapproved for the following reasons: date 2 PermitNo.-------------------------------------------------------------- Issued---:---- --------_____------------_----- date BOARD OF HEALTH TOWN OF BARNSTABLE Certificate ®f Compriance THIS IS TO CERTIFY, Tat the Individual Well Constructed (}P, Altered ( ), or Repaired ( ) by--- �-�---- ------------- Install r at— ---Z- = — --- — Lj hasbeen installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation as described in the application for Well Construction Permit No�—' ��--- ->I-Dated— �If - THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE----------------_--- ___ -— —-- --- Inspector------—- ----- — __--------------------------- r l s Ile No.e Fee ---- BOARD OF HEALTH TOWN OF BARNSTABLE Zipprication-*rVell con5tructionPermit Application is hereby made for a permit to Construct (!/), Alter ( ), or Repair ( )an individual Well at: j?ocation — Address Assessors Map and Parcel AIAII -- - - - - "3 _ , �� .5 r 41-5 ------------------- Owner I Ad ress V ' Installer — Drille/ ( Address v Type of Building Dwelling- �------ Other - Type of Building-----------------------_-_ No. of Persons—�� - ----_____.__-__----------------- Type of Well- -lrVC =—c�°' °'.w `=' '"�= Ca acit e� Purpose of Well- Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation — The undersigned further agrees not to place the,well in operation until Certificate of Compliance has been issued by the Board of Health. ti Signed— ./ ...dt/P ,_st.# — �_- �— -- — C�/ .,r _______ date Application Approved By- --- — t .r '--!? -—— - — � �1!/—, -- date Application Disapproved for the following reasons:------------ ---------------_________—_______________ ------------------------------------------------------------------------------------------------------ ------------- --- - -— —------—--- -- date �" _ Permit No. - - ! -�� ---------------------- Issued--------10- -��!� �-----------_----- -- - ® date BOARD OF HEALTH w f TOWN OF BARNSTABLE 1 z. Certificate Of 4- mPliance THIS IS TO CERTIFY, That the Individual.Well Consti•ucted^0q Altered,( ), or Repaired ( ) by-- - --- ------------------------------------------------------------------------------------------------------------------------- - / Iyn..st�alleer- p y - - =----------- - - has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation as described in the application for Well Construction Permit No. ----Dated THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE-------------------------------------------- ------------------------------------------ Inspector---------------- - -_ - ---------------------------------- BOARD OF HEALTH TOWN OFt��­ BARNS�T_ABLE Iveir con5truction3permit ,,�No.--------------------- A � Fee--------=`-- ---- � t Permission is hereby granted —- fj/ r-^- =------------------------------------------------------ to Construct (A), Alter ( ), or Repair ( ) an (Individual Well at: No. `-=-------- - ------- -u- "/`i'-t---OA-=`Y J Street as shown on the application for a Well Construction Permit I No.---------------------- ----------------------------------- Dated------/ fa (/- - - - ----------------------------- ------------------------ Board of Health V 1 DATE------------o � � --------------------------- THE FOLLOWING IS/ARE THE BEST IMAGES FROM POOR QUALITY ORIGINALS) I M ^C&L DATA ",COMMONWEALTH OF MASSACHUSETTS •+ Department of ;r ENVIRONMENTAL MANAGEMENT IDENTIFICATION DEVICE 1989-90 f EXPIRES JUNE 30, '1990 .'.. . ., i,i I I ... r.!t ii•.I !t.•�. ....n 1 EI Director a meta Trrttf - In-Accordance with the Provisions of Massachusetts G.L. Chapter 21 Section 16 LAURENCE E. WILE PLYMPTON, MA is Authorized to Dig or Drill Wells in the Commonwealth of Massachusetts During the Period JULY 1, 1988, to JUNE 30, 1989 Certif icate No. 88 , SERIAL NO 5285 Director do Chief Engineer i r � tL 50 o — - 6 14-A,:7D Leo,o0 /=-XTEiI/D ALL HPPL/CFI SLE — ex/sfin r-ouna! i-o,ci/e _ A / MANI 1OZ- CO VC= 2S, To W17- / 9 9 P HO,e/�. SCRLE . / VEi2T, SCALE / - /O E t/ ,v —o—o---o—o- lroposed ground PI'of'!le /2.• OF F•/A//SHED G,2f9De- F L o r,Aa ---y- �m�n. %•per •��:� F[.OW 2 layer of .SCHEn. 40-RV.c. Oe CmIn/mum' %"• per fOOf) 3/6" 'pee LSfone EQUAL To se-PT/e- PIPE ro 8e , 7f�_VK r-o" J 14 - LEVEL 1 Z7/S T. 8 OX " p 6 Surn ,4l washed stone �r _Jll / rr f.D, yjN �'. 00 GAL. 5EP7'IG TAIQIG 44 D T-/� / L 5 - LEACH P/T 46 / G� i /�j - - � L O uG E- S -- 3 2 Z55 I I ' 1 13 8� - TEST BY- DO��.E Stiic. E}ZI rVG. _ _� BE�ARooM HoUS'E- . 0 _. 5 ;�'� ! Cr70. dispo_ser� 1�) T. MC- KC-AN {3/ RW.STAf31_E B. of H P. G251 52 11r �� _ K Co-r 35 f��l2C• A2ATE <2- M/,Q '4/CH W/TNESS: _ ; e,,9TE- GALS. DA ,�� /W _ .� \ o �,'EPT/C TAA/k : , 440 x /.5= G 0 G.Ph � � � � I ' � • � N usE: _.L.Ss2� GAL. TAA/� -1'op SUL3501 L cv , LEf�CH/NG F1�2EA 44 5,a � / i (oE'of S1DEWfjLL. 15b,g 2,5 377 d G..P D Cl_ � SA 1,.I D TOTS G. �o• P.� G. D. " / .—. _ 1 q8 �Q: stlgvt�(tstaJ M�s`1TF2 SAUri $p PRoPos / 6O Zo5,30 / u-r-Ilselol(" i�� 48 -' ✓ /_,- - / '�CE2T/F)' THAT 'THE BU/GDW(S NIL WA'T"ER E'KJ 0UI1 t7ER D ,( PAT � W P,20POSED Oti/ TH G E i2o A U/v0 S ' BU ESL r✓��d, 61,3 SI-l0WAJ Oti! . 7H/5 PLAA DOES 48 `q+e6 GBr7 tiCJFKo,2M TO THE BU/LD/ VG SET- — 5/ TE nFGE PLFCI :.— BM= c/a GPAT� )2E0L)1QEMEl/T5 OF THE --- EI-EV. 49.5 TOWAJ OF E3ARNS,'TAE3LE L:OT 36 13UR.5L'F-Y PATH BYI N G PART OF PLAN BOOK q 18 PAGE 55 LS 14 of :`�' w✓y N OF tisq !4 ,. ,r stir � ss94` rIT1-ED WE-,ST PAp15H ACRI~S BAR�457A13LE MASS.' evER�rr H. N P2EPARD E FO12: M I KJ� PAN Z ( L I O \ HIN_KLEY , ,�� , `` vac6�1T VA 'S� 13sso � HINULEY H� - CIVIL ti t . , 1787 a .$CALE: AS NOTED DATE: S F PT 18; 195? PLA A ./ (scALE: r , 40') V I E W t �q10911 o. o o a xr5*/ n e/eva.fion BL DG. SETBAC/G 9 i o.00 p!-oposed elevation �2E4UIQC-ME/VTS : APPROVER t •C!rOr7 - �oA�2D, of HEAG.TH LDGJ t GJELLE� Inc. . S/.alto 7/4 !")A/A/ ST�2EET .MASS /5 • YRI2MOUTH PORT, MASS . . proposed C o n foue-s' - PRQFE55l4NAL EIvGl/VEERS LAND SUMVEY0r2S i �rLtT6 I /n 1c >, L-tS c�> T41 i ! rtI Q L, 50, D — 44,CEO L4o,oo _ _ N T O a EXTEiI/D HLL APPLlCR BLE e�cisfin round ro,Fi/e o• MAN!-TOLEE To ,V COV ,eS WITH/HO)e/z. SGR LE . If /o ��j C T � N VEST, ScAG � , / / o—o--a—o— Propo3•ed ground le min. %4'Pe�-•P- :) FLOW 2- layer of ,. 3/8 pe.. Gt5- one SCHE a 4o P. l�c. 02 �rn/n/mum Per too f EQuf1L To .SEPTic R Pipe ro BE �_ Tf�VK-� -�3•/yr�l. io� l4p. � �� � • LIQUID D1577 BOX I ,.. . LEVEL sump ` washed stone � �,.;r� _t -OO GAL, SEPTIC TANG .: 44 D � Tle�:) / L S L EACH P/7" . G Q P Tit��!- 7-c-S-r 463%r�- U 15 F'F%1 N"5- O �.. no c/isposer ; 52 5 PE,2C. ,2ATE• <2-_� M/JV. /AlGN WI TNESS ,"T- Mc- K��N , l3AI�t`.!STAQt_t B. of H • P. G2 51 LOT 35 d p Z- o R,197 440 G AL S.h 3 ��. • D � � � ° � $E P T/C TfI Nk : ' 44 X /.5= G 6 0 G.P,D• - � I �° • vSE: _1 ov Gf)L. TA AIL' u so .,.. 5 O IL LEyG'H/1VG 12Ef� ' $0 44 8„ a S/DEGJfjLC.: 150,g z.2 3?7, a G.P. _ � �.. .��of �J►.m. - " s / = •BOTTOM 113. 1- 1 .o 46 o.!" D SAND TO7 F3 L � r i >a . ' c _ z GAO N (Z, 4 x c ��_i� �'T 72, _ ... . _N o ice- SE•�t ,,-c=CAT s � M I�D I V M W ITH 5� co513t=E.S AND 5 tL�T 50 , =PRoPo3Ep �� --� �- 60 30 -u-r1 cs 36.0 - •_ No WKrER E'N COI.IWTERI:D __ / GE2T/FY THAT THE BU/LD/AlG AB : �- �A-->�,.I Q3 GF�.aT� PROPOSED ON. THE G�'OUN� flS ELfiV. �1,3 SHOW/V ON TH/5 P4-A DOES. 0 46 CO�I.lFo2M TO Tl--I E BUILD/IVG 5a-= S l T E _ S E w� G PL/� I�1 %k .=--BM=C�8 GRATE BRCfG F2E QUl2EME/VTS OF THE 50--- ,,r ,l� EL.Et/. 49.5 TOW/V OF B/�RNS'TAI[3L-E' - :F02 : LOT 3 6 C3U RSL�Y PATH +.. Bit N PAFZT O� PL_AN BOOK 918 ,PAGE 55 •►', . � ��r r�i ass... -r I TL ED W EST PAF 15 H AC 9EES $AFISTA 13L.r M,A.55. ti or ' fYE?ETT N. `�'; MIKE- PANZ ( LIO C 1- EVEREi7 H. PREPARED FOR: HINCKLEY i �.' 13230 HfiICKLEY -P CIVIL <a ti ; 1 87 0 $GALE: AS NOTED DATE: 5 E PT-. 18 , 19Sq J , "-- PLA !V SCALE: /" • 40 � V 1 E �/`I E o• o o a x/s�-/n q e/evay-ion SL DG. .5ETBACIG. i2 E G?U/�Q E M E/V T S : F-1�P�24!~I E D ---- LO��.1 � I E L L Ems, nc. o.o o proposed e/e Vatiora 30 • - �'ro/'I BOARD OF HEALTH - dS �14 MR/N STeEE T IL x/Sfn qcon-fov�-s YR�2M0UTH PO27, MPSS . e o Y- 'Proposed c o n fO UrS • PFz4FE55lONAL 'E�.IG/NEEf25 � L�91/D SV2VEY0r25 � 8 9 r//� t