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Home My WebLink About0049 BURSLEY PATH - Health 49 �Bursley Path W. Barnstable P 1R t TO-WN OF BARNSTABLE LOCATION qq �I1� PraSJ(n #�r��j� VILLAGE 91 -%.rn5 ASSESSOR'S MAP&PARCEL IN&TvW+E0X0S NAME&PHONE NO SEPTIC TANK CAPACITY (5� LEACHING FACILITY:(type) Pi"r5 (size) 10W NO.OF BEDROOMS] ' OWNER Loc.ZK-0q PERMIT DATE: DATEv, //6 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 f J f I r f i f Lf4lLF\r♦fLFtJLi♦JLF\JLJ\Jtf4fLr4fLr4fLr4JL{4{ 4 \ 4 4 4 4 4 t 4 t 4 4 t 4 t ♦ 4 L \ 4 4 4 t 4 4 �k 1 L L 4 L ♦ t t 4 t ♦ L t \ t 4 L 4 ♦ 4 ♦ ,' f J J J F J f f f f f f J f { f f \ �LJ.1p� ♦ \ \ \ 1 ♦ 1 ♦ \ 4 ♦ 4 \ ♦ ♦ ♦ t \ 4 \ \� Sd4 ♦F4ftF4ftF4 f4 ♦f4 4 \ J ftd4f1J4J♦J4F - , ♦ L t L L \ 4 \ t k L 4 4 t 4 L \ 4 4 \ 4 L k \ 4 L ♦ \ 4 \ t 4 4 4 ♦ 4 4 \ 4 4 4 4 4 \ \ \ 4 4 4 ♦ 4 ♦ 4 \ 4 ♦ 4 \ 4 ♦ 4 4 4 \ - I♦ L 4 L \ 1 L \ \ 4 k 1 ♦ t t 4 \ L L \ 4 \ t L ♦ L ♦ 4 ♦ t ♦ L{ f r f r J r { f { f r f r J r f r J r J r r i J i J { J r J -. •_ i♦{♦f\f♦{\F4f\J�{ f l f f ! f ! J J 17 4 l \ ♦ 4 \ 4 4 35 46 : ems y max 1 <LCommonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 'aM 49 Bursley Path + — Property Address Dan & Mary Luczkow — Owner Owner's Name information is West Barnstable MA 02668 June 26, 2010 — required for every page. Cityrrown 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: A. General Information When filling out forms on the I ,� computer,use 1. Inspector: only the tab key to move your Patrick M. O'Connell _ — cursor-do not Name of Inspector -- use the return key. Septic Inspection Services Co. — Company Name rab 189 Cammett Road — Company Address Marstons Mllls MA 02648 — ennn CitylTown State Zip Code 508.428.1779 SI 12855 _ Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and.that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails w ❑ Needs Further Evaluation by the Local Approving Authority E P June 26, 2010 Job# 10-161 — t]_ I pector's Signature Date m M 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 a 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 C> o and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. v/j a t5ins•09108 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 1 0±17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 49 Bursley Path Property Address Dan & Mary Luczkow — Owner Owner's Name information is West Barnstable MA 02668 June 26, 2010 required for every page. CitylTown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: Recommend pumping tank leaching pits show no signs of surcharge or hydraulic failure. B) System Conditionally Passes: ❑ one or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 49 Bursley Path — Property Address Dan & Mary Luczkow — Owner Owner's Name information is West Barnstable MA 02668 June 26, 2010 — required for State Zip Code Date of Inspection every page. Cityrrown — B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•09108 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 3 of 117 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 49 Bursley Path — Property Address Dan & Mary Luczkow — Owner Owner's Name information is West Barnstable MA 02668 June 26, 2010 — required for every page. Cityfrown State Zip Code Date of Inspection — B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: _ ** This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each of the following for all inspections: Yes No El ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than_day flow _ t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 49 Bursley Path — Property Address Dan & Mary Luczkow — Owner Owner's Name information is required for West Barnstable MA 02668 June 26, 2010 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 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 D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area (Interim Wellhead Protection ❑ ❑ Area—IWPA) or a mapped Zone II of a public water supply well ~ If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 49 Bursley Path — Property Address Dan & Mary Luczkow — Owner Owner's Name information is West Barnstable MA 02668 June 26, 2010 — required for every page. CityTTown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® El available as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® El approximation in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 5 Number of bedrooms (actual): 5 — DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 550 t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 49 Bursley Path — Property Address Dan &Mary Luczkow — Owner Owner's Name information is West Barnstable MA 02668 June 26, 2010 — required for every page. City/Town State Zip Code Date of Inspection — D. System Information Description: Unknown — Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Well Water Detail Sump pump? ❑ Yes ® No Currently Last date of occupancy: Occupied. Commercial/industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 49 Bursley Path Property Address Dan & Mary Luczkow Owner Owner's Name information is required for West Barnstable MA 02668 June 26, 2010 - every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: None _ Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): (Sins-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 49 Bursley Path — Property Address Dan & Mary Luczkow Owner Owner's Name information is West Barnstable MA 02668 June 26, 2010 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Compliance date: 9/8/88 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 5' _ Depth below grade: feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): 4' _ Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No 10.5' long x 5.8'wide- 1500 gal._ Dimensions: Sludge depth: 15ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 o1 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 49 Bursley Path — Property Address Dan & Mary Luczkow — Owner Owner's Name information is West Barnstable MA 02668 June 26, 2010 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 24 _ 6" Scum thickness Distance from top of scum to top of outlet tee or baffle 6 Distance from bottom of scum to bottom of outlet tee or baffle 7 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.): Recommend pumping tank. Tees were intact and liquid level was at bottom of outlet invert. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date 15ins-09108 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 10 of 17 _ - l Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 49 Bursley Path _ Property Address Dan & Mary Luczkow _ Owner Owner's Name information is required for West Barnstable MA 02668 June 26, 2010 - every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: - gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No !Sins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 49 Bursley Path Property Address Dan & Mary Luczkow _ Owner Owner's Name information is required for West Barnstable MA 02668 June 26, 2010 - every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 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.): Trace of solids carryover, no high stains. Liquid level was found at bottom of outlet pipes. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•09/08 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 12 of 17 1 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 49 Bursley Path Property Address Dan & Mary Luczkow _ Owner Owner's Name information is required for West Barnstable MA 02668 June 26, 2010 - every page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: Two 6x6 pits. — ❑ leaching chambers number: — ❑ leaching galleries number: — ❑ leaching trenches number, length: — ❑ leaching fields number, dimensions: — ❑ overflow cesspool number: — ❑ innovative/alternative system Type/name of technology: — Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching pits showed no signs of surcharge, were too deep to excavate. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration — Depth—top of liquid to inlet invert — Depth of solids layer — Depth of scum layer — Dimensions of cesspool — Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 49 Bursley Path Property Address Dan & Mary Luczkow _ Owner Owner's Name information is required for West Barnstable MA 02668 June 26, 2010 - every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: — Dimensions — Depth of solids — Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 49 Bursley Path -------- ------ __ ---- __.._. ___... _... - . Property Address Dan & Mary Luczkow ___..___..____ ____.____--------.----- Owner Owner's Name information is west Barnstable MA 02668 June 26, 2010 required for --- -- --"---- — every page. CitylTown State Zip Code Date of Inspection — D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ❑ drawing attached separately 17 . 13 35 46 4 . Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 49 Bursley Path Property Address Dan & Mary Luczkow Owner Owner's Name information is required for West Barnstable MA 02668 June 26, 2010 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 30+ feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health =explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Low area of property on opposite side of road with no surface water is 30-40 feet lower than SAS. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 • Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 49 Bursley Path — Property Address Dan & Mary Luczkow — Owner Owner's Name information is West Barnstable MA 02668 June 26, 2010 — required for every page. Cityrrown State Zip Code Date of Inspection — E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 a zw 3e.\ COMIvrONWEALTH OF MASSACHUSETTS z EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS c DEPARTMENT OF ENVIRONMENTAL PROTE�+CTION 1N S`ey� MAR 2 1 Z005 TOWN OF BARNSTABLE TITLE 5 HEAJ TH DEPT. OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 140, (� �� r,t$ GL to /� t1 Owner's.Name• Owner's Address: ,4q A-;, , Date of Inspection: :�Ljq/(,S Name of Inspector: leaseprint) AAonar- Company Name: Rr�r `r b Nh s�)Xle onz7-r, Mailing Address: P0, 8. ,::,4, r)oq Telephone Number: ,;�-r)';J- 9-cry 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.function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant tot ection 15.340 of Title 5 (310 'MR 15.000). The system: t' Passes Conditionally Passes Needs Further Evaluation by:the Local Approving Authority ails Inspector's Signature: mate: 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 tl-as inspection. If.the system is a shared system or has a design flow of 10,000 w a ubmit the re ort to the a ro riate regional office of the gpd or greater,the inspector and the system o ner sh ll s p pp p DEP. The original should be sent to tre system owner and copies sent to tie buyer, if applicable, and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection ar_d under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/20.00 page I Page 2 of 1 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: hAQ01 P Pda a i Owner: Date of Ins ections P J'?&k InspectionSummary: Check A,B,C;D or E/ALWAYS complete all o=Section D A. S stem Passes: I have not found an information which indicates that an of the fai_ure Y y criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria.not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system component,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,NND) 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(wsether metal or not) is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent:System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation.of..sewage backup or 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 l 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: 2 ' Page 3 of 1 I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 7 9 AY'4. ' P,11_ ___ PP �Y, .:fit-t'n �^ /� Owner: t)J1 omo (itsival�� r, Date of Inspection:t 4fto/�` 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, safery or the environment. 1. System will pass unless Boar of Health determines in accordance with 310 CMR 15.303(i)(b) that the system is not functioning in a manner which will protect public healt:i,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 Dr 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: 3 Page 4 of I 1 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS ' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) r` Property Address: } 11 Owner: 01,01e 2v 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 Backup of sewage into facility or system component due to overloaded.or clo�Qed:SAS or cesspool Discharge or ponding of ef_luent 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&e to an overloaded or clogged SAS or / cesspool Liquid depth in cesspool is less than 6"below invert or available volume is less than %day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number V. of times pumped _ Any portion of the SAS,cesspool or privy is below high grour:d water elevation. Any portion of cesspool or privy is within 100 feet of a surface water.supplyor tributary to a surface water supply. _ Any portion of a cesspool or privy is within a Zone 1 of a:pubhc well. Any portion of a cesspool or privy is within 50 feet of a.private water supply well. Any portion of a.cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. f 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 faci_ity 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. fio (Yes/No)The system fails. I have determined that one or more ofthe above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E: Large Systems: To be considered a large system the system must serve a.facility with.a design flow of 10,000 gpd to 15,000 gPd• You must indicate either"yes"or"no"to each of the following: . (The following criteria apply to large systems in addition to the criteria above) yes no the system is within 400 feet of a.surface drinking water supply the system is within 200 feet:of a tributary to a surface.drinking water supply the system is located in a nitrDgen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water sup?ly well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of an large system considered a y P Y g Y significant threat under Section E or fa0ed under Section D shall upgrade tie system in accordance with 310 CMR Pb ) 15.304. The system owner should contact the appropriate regional office or the Department. 4 Paae 5 of 1 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: AomLpa—el—/ Owner: a2�042-9 I/b-21ab Date of Inspection: Check if the following have been done. You must indicate"yes" or"no"'as to each of the following: Yes No Pumping information was provided,by the owner,occupant, or Board of Health Were any of the system components pumped out in the previous two weeks? Has the system received normal flows in the previous two week period ? Have large volumes of wa:er been introduced to the system recently or as part of this inspection ? Were as built plans of the system obtained and examined? (If they were not available note as N/A) Was the facility or dwellir_g inspected for signs of sewage back up Was the site inspected for signs of break out? Were all system components, excluding the SAS, located on site Were the septic tank manholes uncovered;opened, and the in_erior 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 owne-)provided with information on the proper maintenance of subsurface sewage disposal systems The size and location of the Soil Absorption System (SAS)oo the site has been determined based on: Yes no Existing information. For example, a plan at the Board of Health. a� Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)] 5 Page 6 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTIONFORM PART C SYSTEM INFORMATION Property Address: 7 ! < � Owner: m x f Ld�g'N/1Z �11;/Le'. =CA i Date of Inspection: FLOW CONDITIONS RESIDENTIAL r Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.2.03 (for example: 110 gpd x#of bedrooms): Number of current residents: a Does residence have a garbage grinder(yes or no): Is laundry on z separate sewzo�e systems(yes or no):�.[tf yes separate inspection required] Laundry system inspected (yes or no): Seasonal use: (yes or no): IQ Water meter readings, if available(last 2 years usage(gpd)): Sump pump(yes or no):_ Last date of occupancy: COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readin-s, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records . 9 + Source of information: (�iU 9003 Was system pumped as part of the inspection(yes or no): no If yes, volume pumped: gallons -- How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM 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) Tight tank _Attach a copy of the DEP approval _.Other(describe): Appr:ximate age of all components,date installed(if known) and source of information: Were sewage.odors detected when arriving at the site.(yes or no):( 6 Page 7 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM.INFORMATION(continued) n Property Address: q9 Owner: P Date of Inspection: �gJ/y 14 's- BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction:_cast iron _40 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints',venting; evidence of leakage;etc`): SEPTIC TANK: (locate on site plan) _ 1 Depth below grade: Material of construction: ✓oncrete_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) b 1 Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: J Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: How were dimensions determined: Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage,etc.): / ( � ; A� 9 .i�: l"� '�' `Tc� 0/ , GREASE TRAP:(101(locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_fiberglass polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of Inkage,etc.): 7 Page 8 of 11 ' OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS - SUBSURFACE SEV4`AGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: t1U ,n9 j ti.t � i Date of Inspection: `"'-/Zj jb5_ TIGHT or HOLDING TANK: At(tank must be pumped.at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions.` Capacity: gallops Design Flow: gallons/day Alarm present(yes or no): Alarm'level: Alarm in working order(yes or no): Date of last pumping: Comments (condition of alarm and float switches, etc.): �J DISTRIBUTION BOX:, f present must be opened)(locate on site plan) Depth of liquid level above,outlet invert: ME✓ �C Comments (note if box is level and dis-.ribution to outlets equal, any evidence of solids carryover, any evidence of lea age into or out.of box, e c.): PUMP CHAMBER: (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments (note condition of pump chamber,condition of pumps and appurtenances, etc.): 8 'Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTE INFORMATION(continued) Property Address: �19 2 ;v , Owner: /1J4,&e A Date of Inspection: ✓ > ,"a� SOIL ABSORPTION SYSTEM (SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type t ' leaching pits,number:_ Teaching chambers,number: leaching galleries, number: leaching trenches,number, length: leaching fields,number, dimensions: overflow cesspool, number: innovative/alternative system Type/name of technology: Comments(note condition of soil, sigr_s of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): V mvsr 127 CESSPOOLS:(cesspool must b-,pumped as part of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of.groundwater inflow(yes or no): Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): PRIVY:%(locate on site plan) Materials of construction:. Dimensions: Depth of solids: Comments(note condition of soil, signs of hydraulic failure, level of ponoing, condition of vegetation, etc.): _ 9 _ Page 10 of 11 OFFICIAL INSPECTION FORM—,NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: V9 °: Ce /'� � n 1,� �1 ma— Owner: l JlI1L, KA1 o er�,e N Date of Inspection: e 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 1'00 feet.Locate where public water supply enters the building. lqnk = 4-0 1316 e) 10 Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: C 1 JJ�r Owner:0 At KA Date of Inspection: (r��s_ SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 3% feet Please indicate(check) all methods used to determine the high ground wa_er 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 Hezlth-explain: -hecked with local excavators, installers- (attach documentation) - Accessed USGS database-explain: You must describe how you established the high ground water elevation: r 11 Permit Number: Date: Completed by: ` HIGH GR:1.UND=WATER LEVEL COMPUTATION Site Location: jJ� , r Lot No. Owner: 1�� '9�jn Address. Contractor: / /` r'//yf7L/� C.L / S/� Address: Notes: Z 4�Xs STEP 1 Measure depth to water ta'ole _ to nearest 1/10 'it. ......................................................... ... .Date month./day/year i STEP 2 Using Water-Level Range Zone and Index Well Map locat- i site and determine: '55 O Appropriate index we-I................................ 5!� �Z I _ I B. Water-level range zone ...................................................... STEP 3 Usingmonthly report "Cu-rent Wat. Resources Conditicns" determine current depth to r�r/ d water level for index well ........................:.. zk� Zl"1 I month/year i I STEP 4 Using Table of Water-leve Adjustments ( .I nor index well (STEP 2A)_ current depth to water level.)or index we l (STEP 3), i and water-level zone (STE' 2B) determine water-level adjustment .......................................................................................... 7 � STEP 5 Estimate depth to high wa-er by subtracting the water- level adjustment (STEP 4_ prom measured depth to water level at site (STEP 1) ...... ...................................:................... ................................................. 13� S Figur 13.--Reproducible computation form. 15 4v J +w. .......�,,,........�..........,,.z,.... .�„I..a.�A^ _,._.__._....._..�..._....,......_..„ �._.......W...._...�... _.�.,...........�....__�.,,...,'x ....w._.;:,I�.:_......___.... ...,,, wa��h iF'�wi r#.N.w__...,...- - (C/we) P � �_�._..._._._..�._............_.._��: _. _._. _:. __.. ........._.... 41 ` TOWN OF BARNSTABLE LOCATION SEWAGE # p �J VILLAGE U"ten' (/Z. ,,, �,� � ASSESSOR'S MAP & LOT 4 INSTALLER'S NAME G PHONE NO. SEPTIC TANK CAPACITY s�ISG LEACHING FACILITY:(type) (size) /p.00, 4 v NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No `�� ., �_ �� N 3� -ry O r" � \. � � �� ti �� .:F ^ -7 s No.--•1. :. 1-- Fns .J--��- r' ...- .5..' '. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ........... -.....OF............... .-...............-.... --- ............................ Appliratinn for Dhipaoa1 Works Tnntrnrtion Prrmit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal S stern t o1 es _ %----------------------- --------------- ------._...........--- _ _ � a.�ocy. d ��A. y _ A dr s / a ...4r�---1.10 4 . .. ........................... ... ....................................... Insr Address Type of Buil n Size Lqk.�b'___________Sq. feet U Dwelli o. of Bedrooms--- Attic ( ) Garbage Grinder ( ) '-4 Other—Type e of Building No. of ersons____________________________ Showers — Cafeteria Pr yP g P ( ) ( ) P4 Ot er fixtures ._.•. d Design Flow_ a_�_________________ allons per per on er day. Total daily flow_-,_0_____________________________gallons. W WSeptic Tank—Liquid capac .......1 a1fan) Le t,��co _ .. Diameter_______________ Depth................ x Disposal Trench—N n__.�Width______ ._ Total LengJ _l�__________________ Total leaching area....................sq. ft. Seepage Pit No--------- ___�iameter............._...... Deptli�iellwkin t______:____________ Total leaching area..................sq. ft. -- Z Other Distribution box ( ) Dosingtank ( ) _ll// % Percolation Test Results Performed by... Lt__ .•%__.___. .. .ls _.3�'______________________ Date_______ � l?______.__.._.. � Test Pit No. 1................minutes �nch De th of T rt____________ Depth to ground water........................ �, Test Pit No. 2________________mmutes er inch ep rof es its. _ ____ epth to ground water.........-.............. PD T &"D x Description of Soil....../ U ••••-•••-•-•---••--•-•••••••-•----•--•-----•---•-••...-•••••-••••-••••••---•------••-••••.....-••••-••••-•••••••............•---•••••---•••... - W ---------------- ----------- ----••-•-•-••••-•••••-----------._...•••--•--••---•---•••••••-••••--••-----------------•-------------------.............................................................. 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 TITS:;^. 5 of the State Sanitary C e The undersigned further agrees not to place the system in operation until a Certificate of Compliance has be n i by the b rd of health. - • - Signed -11G l "Te� SL.-�.cJ....._ Date Application Approved By-•••••.. " ..-`•^T!r-" -'" 1 ,- Date Application Disapproved for the following reasons-----------------------------------------------------------------------------------------------------------•-•--- -••.................•-•-••-•-•••••-•-•-•-----••-••--•----•--••••-•--••-•...•••-••••••---•-•••••-•--•...--••-•••-••••••-••----------•----•••-••--•-•-•----------••••-•--._.-----------------••-•••••••--- Date PermitNo...... ---5-t----------------------- Issued....................................................... Date /_44 No.... ..�....�....7. FRs....Z. i............... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALgT�H, 1 -------- OF..............Ir.« :' - -�C.............................. Appliration for Binpnnal Works Cfnnntrurtion Prrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal S stein at: p X1. Al ... ..._.... -� .. ....... ........... ................................................... .............. Lo No. • •. -------••----------- ress I .... ocarion r ... .... ................ . Yl Ad s /iO 7` F Ins ller / Address UType of Buil 'n Size Lo _ .�--•---•----Sq. feet ,., Dwe11iV�No. of Bedrooms............--------------------------------Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Ga Olher fixtures . W Design Flow_ __.S_________________��' �gallons per per on per day. Total daily flow.� ,7 ._.__..__._.___._.__._.__.._.gallons. WSeptic Tank—Liquid capaei y�___..__(galfor� Le�tliv .�LJ'01h________________ Diameter__.____________. Depth_._.___..__.__.. Disposal Trench—N ........�_.Width_...._. . Total L! ............... Total leaching area....................Sq. ft. Seepage Pit No--------- eter.................... Deptfi-%elU ...e___......._......... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosin tank Percolation Test Results Performed by._ - _ � ___.___.l _ &..r....................... Date_/.,!'y/�..1.............._. aTest Pit No. 1................minutes ranch Depth of T�s Pit------------4..__ __ Depth to ground water----------------------- Test Pit No. 2................minutes per inch PVApth of Test Pit._......__..._._. Depth to ground water........................ O ...•-•...••. Description of Soil----- = } 1 :_... == x 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 TIT1.;e. The undersigned further agrees not to lace the system in p 5 of the State Sanitary Code T g g p y operation until a Certificate of Compliance has been i ' d by the oard of health. Signed.. — . 1 -------------------- Date Application Approved By......... -------:�D `""K".c"" •.......................•----•--- ----•-• - t 5 Date Application Disapproved for the following reasons:......................'......................................................................................... -------------------------------------•--•-•----------------------•--------•------•---.......-•---•------.-•--•••--•--•----------•-------•-•-•--•-•----------------•------------------•------•-•--------- Date PermitNo.....Ly--------� ....................... Issued Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ` � OF...........( - :- - r.................................. Trrtgfiratr of Tnutphaurr THIS IS TO CERTIFY, That,th ndividual Sewage Disposal System constructed >,—) or Repaired ( ) b . E r✓ -a rr.t....... J. ^1.�= •---•--•-------------------•--._------------------.........._....------------....................------•-----.....---.......... y............... [z fJ y` ' U Installer at...............i._a. .....-- �-�aa _ --------�Z.Ov,�------ --------------•------------------------........................................................ has been installed in accordance with the provisions of TITLE j of The State Sanitary Code as described in the application for Disposal Works Construction Permit No----- ............ dated------------------------------------------------ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE......................L--^-4_-_Y...........----•-...------------.. Inspector................... _ 'THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ......f. .`L:.:::-:.............OF............C't�' .,,—,—.-4.- s�.� .................................. FEE. S� ....... Disposal Workii Tonotrudivit Vanfit Permissionis hereby granted......... -•---- -------•------------- .............................................................. to Construct � or Repair ( ) 'an IndiSewa a isposal System atNo...........1_ t,..7--------? ��✓ ........... -W..._. Street rr�� r _ as shown on the application for Disposal Works Construction Permit No.L1ll'J_\�1�._,Dated.......................................... -•---------------•-•••-••--------•- + '----------------------..._......----•..........•---- � z DATE---------............. ............................. U7 Board of Health FORM 1255 HOSES & WARREN. INC., PUBLISHERS Departfnent of E'Svironmenj.n.gern,'ent/Division of Water Resources VON WATER WELL COMPLETION REPORT Gal r k WELL LOCATION Address— City/Town. G.S.Quadrangle Map Grid Location Owner r n"w t e K C�. (� Address VO . lOX- '34-1 C... S( L-i �C�, .iX(y 02%3� WELL USE CONSOLIDATED WELL Domestic[Y Public ❑ Industrial ❑ Type of Water-bearing Rock Other Water-bearing Zones KAe r.- 1) From—To— Method Drilled 1 2) From—To— Date Drilled 3) From To 4) From To ,/fi a 0 C Diameter ASING y Depth to Bedrock Length r Type 1" Ia ,�" C.- UNCONSOLIDATED WELL STATIC WATER LEVEL Water-bearingMaterials i Feet below land surface_ Sand: fine❑ medium Q coarse Qf Date measured 0 Gravel: fine❑ medium❑ coarse[] GRAVEL PACK WELL Screen: Slot# / length r from to Yes ❑ No Split Screen (or 2nd screen) WATER QUALITY TESTS MADE. Slot# length from to F Chemical ❑v Biological ❑ Depth To Bedrock PUMP TEST 4� Drawdown y feet after pumping�Jdays 1 hours at P 0 GPM. How measured C Cr_k �� t��n Recovery feet after hours. LOG of FORMATIONS COMMENTS: (On well or water) Materials From To 0 Pr \L�m 0 a� ro e DRILLER ` oGwr Firm � MTI Well o a Address IPr. 3 V 80 0 \ City L"res f CIA le Registration No. 4 perator'ssSignature Please print firmly BOARD OF HEALTH COPY 25M•10-85-807101 rli!tlinititmtlSflit ttiSiitlnilte?tit►ttinfi4i?tittiitT1Tlil►iM114t1fitli MTtilt'llRTiitttt191iiitflfiilitil 1.!! lnVIMlf►ttnlltititittiltirTTMVMtitlfMIrTi'itti�tiitt't!i►itti"Iililtttf!ftlttliPi3'tt it�xiitit��, ; E VIROTECH LABORATORIES 449 Rte. 130• Sandwich,MA 02563• (617)888-6460 =a CLIENT: Peter Iiawley RE LOCATION: Lot 2 Cedar St. — t ADDRESS: Box 317 W. Barnstable E. Sandwich MA 02537 COLLECTED BY: Meehan SAMPLE DATE: 2/11/88 TIME: 10:15 AM DATE RECEIVED: 2 1.1 88 SAMPLE ID: E 648 JOB New Well WELL DEPTH: z� RESULTS OF ANALYSIS: Parameter Units Recommended limit Result Conform bacteria/100 ml (MF Method) 0 g 0 pH pH units 6.0-8.5 7.05 ---- - --- %zl Conductance umhos/cm 500 75 ca Sodium mg/L 20.0 7.0 a Nitrate-N mg/L 10.0' <.05 u M Iron mg/L 0.3 <.OS a Manganese mg/L 0.05 Hardness mg/L as CaCO 500 �! - Sulfate mg/L 250 Potassium mg/L 20.0 Alkalinity mg/L 200 Chloride m /L 250 ~ r :Y COMMENT: Xv ❑ WATER iS SUITABLE FOR DRINKING PURPOSES FOR PARAMETERS TESTED fl �,. DATE r`'+�+ff�liaitlf�41111u�{iid�a�ilu%ittill1ii1}1��llllil��il�#i�ilii�fi�tlia11�11111i1i�11�s�li�l��1,'c�'i�ll�Ililli jls�i��iiaillll�l�'' fsii#i�3lli�E4�itlf�uill��lillii�111%i111�It�llltiuuiittli�t�at'�%4`'° SOIL LOG . N0. 1 6 0 NO . 2 SITE PLAN Notes : / 1 1. If soil data is inconsistent'19 A. tJ 1 with soil log as shown, contact Engineer f w 2 and/or Barnstable Board of Health. 2. Well and Septic locations in 3 accordance with Master Plan. • �_r 64- 4 3. Soil Tests performed by Doyle , 5 TOP OF FOUNDATION EL Engineering Associates, a, f G •• i . •.• fir.::.,.'-'.�>•�"13iW..r- '-.tti. s_...;.,,,,,:..w.a,.'�+•srsirc.._. ,.ar�.., / � 4 1 ✓G/ _ 9 to -- _____ 7, Mao- 2 COVER 1/e 3/1 WASHED STONE WAIr A 12 IM.IL. IN I 1':�, s : o 0/1 W/ 6" SUMP IN It ,ae�re, : , , 3/4'� 1-1/2 0WASHED STONE �"��`" 13 4 LIQUID LEVEL I • •� r 14 . • i �� ° • 6'EFF. DEPTH ' ' ' 15 PERC TEST RESULTS PRECAST SEPTIC TANK WITH ° .•o 0 ea • ��^.tb � PERC RATE :':o •d e I f, , PRECAST LEACHIN6 PITS CAST IN PLACE INLET AND EL. � ;� F NO.: SIZE : `� x� `f-F � .: WNITNESSEO BY : 7 OUTLET T "S PER TITLE Y S IT Z Q � -��'a� - . f� BOARD OF HEALTH SIZE : 15Dla t` DIA . _ DATE : rDIA . -r H \ wo a ATc�G i IJOR TH ARROW AJO-r TO SE US&D FOR SOLAR PL ACE" ;°v T P r PROFILE OF PROPOSED SEWAGE SYSTEM ti � SYSTEM DES16NE0 BY THE TOWN OF �� T � ' REGULATIONS AND � � �-:=�;r�,,��-.�� / r �5 _ RR STATE TITLE V FOR SUBSURFACE DISPOSAL OF SEWAGE S ASE �/4 1 0 "'�`-` ` �'` �� T'°.." a� °� ........................ .`' Aw- N . S . a \ \\ - 1. ALL !PIPES SNAIL BE SCHEDULE 40 P.Y.C. SEWER PIPE 2. All PIPES SNAIL BE SLOPED 1/4 PER FOOT EXCEPTFOR THE FIRST 1 FEET OUT OF THE 0 / 8 WHICH SNAIL BE LEVEL 3.. DESIiN FLOW BEDROOMS AT 110 6ALDAY PER BR . : --40 GAL/DAY SEPTIC TANK SIZE X >Q 6AL. x USE 6AL. W/ %. _ 6ARIA6E DISPOSAL �� 5 LEACNINI SYSTEM: USE (_Z } ?�C--c—, . __ r_141A►/n \ To EFFECTIVE AREA: SIDE=% 7' �` -�i" \ I '% f� \ BOTTOM ft` �� T `o TOTAL FLOW '" -- 7O TOTAL REQ'0 FLOW 4-4-0 X '� = 44J W/r'� GARBAGE DISPOSAL �� o '- _ - o ( �- RESERVE FLOW G1L/ oAY (05 N 11 - 54 30 E Z GB.TO REFERENCE PLANS : i� l �3 -�. -�' . : ;. OC - , - '3 �3 JB,73 i'�'�t� APPROVED BY : = " , BOARD OF HEALTH � _ ,,w t DATE : PROPERTY OWNER : �. SITE A PLAN j -E f e, 1-4- Aj e!:�_ -Y, /� BED ROOM SINGLE FAM 11.'�( fPwgLA 1 N G 'w pAUL ( _ A. LOT_ e 2 1�iO t2 LC-y ��rR TH o. 32 - DA TE --\ ( LA�o s "' ' j t M HIJ f f 2 3 5 1 MOE VIN �! f .