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HomeMy WebLinkAbout0186 CAPES TRAIL - Health 186 CAPES TRAIL, W. BARNSTABI�E A= 088-007. 003 6LD - �� i i } f4�^ No. 4210 1/3 BLU [Ps n(f EQ p sn ESSELTE 10% (D o m ° Commonwealth of Massachusetts 8g 'dd-Z-do3 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 186 Capes Trail a Property Address �. Tim and Deborah Hobill Owner Owner's Name information is required for every West Barnstable '� Ma. 02668 05/23/2016 page. City/Town State Zip Code Date of Inspection ►+ t. 1 Inspection results must be submitted on this form. Inspection forms may not be altered in an way. Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms on the computer, Ili use only the tab 1. Inspector: key to move your cursor-do not Michael T Bisienere use the return Name of Inspector key. Cape Septic Inspections VI �y Company Name 624 Old Barnstable Road Company Address Mashpee Ma. 02649 City/Town State Zip Code 508-280-3356 S13938 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 ❑ Needs Further Evaluation by the Local Approving Authority 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 is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 186 Capes Trail Property Address Tim and Deborah Hobill Owner Owner's Name information is required for every West Barnstable Ma. 02668 05/23/2016 page. Citylrown 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: 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•3/13 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 186 Capes Trail Property Address Tim and Deborah Hobill Owner Owner's Name information is required for every West Barnstable Ma. 02668 05/23/2016 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): 5 , ❑ 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments w 186 Capes Trail Property Address Tim and Deborah Hobill Owner Owner's Name information is required for every West Barnstable Ma. 02668 05/23/2016 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes . No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/day flow t5ins-3/13 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 *M 186 Capes Trail Property Address Tim and Deborah Hobill Owner Owner's Name information is required for every West Barnstable Ma. 02668 05/23/2016 page. Citylrown 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts. W Title 5 Official Inspection Form 's Subsurface Sewage Disposal System Form -Not for Voluntary Assessments • 186 Capes Trail Property Address Tim and Deborah Hobill Owner Owner's Name information is required for every West Barnstable Ma. 02668 05/23/2016 page. Citylrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CM 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 353.7 GPD t5ins•3/13 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 ,.•'° 186 Capes Trail Property Address Tim and Deborah Hobill Owner Owner's Name information is required for every West Barnstable Ma. 02668 05/23/2016 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonaluse? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: occupied Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 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 186 Capes Trail Property Address Tim and Deborah Hobill Owner Owner's Name information is required for every West Barnstable Ma. 02668 05/23/2016 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: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 186 Capes Trail Property Address Tim and Deborah Hobill Owner Owner's Name information is required for every West Barnstable Ma. 02668 05/23/2016 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 19"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): Depth below grade: 12"feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: standard H-10 1500 gallon Sludge depth: 3" t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 186 Capes Trail Property Address Tim and Deborah Hobill Owner Owner's Name information required for a very West Barnstable Ma. 02668 05/23/2016 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 apx. 35" I Scum thickness 1" Distance from top of scum to top;of outlet tee or baffle apx. 5 Distance from bottom of scum to,bottom of outlet tee or baffle apx. 12" How were dimensions determined? sludge Judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): I would recommend the new owner put the tank on a maint. plan with a local septic pumping co. based on the future use of the home.The Barnstable Health Dept has a list of local pumping co Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M SV• 186 Capes Trail Property Address Tim and Deborah Hobill Owner Owner's Name information is required for every West Barnstable Ma. 02668 05/23/2016 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 anld float switches, etc.): I •Attach co of current pumping Contract(required). Is co attached?copy p p g i copy El Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 186 Capes Trail Property Address Tim and Deborah Hobill Owner Owner's Name required for is every West Barnstable required for eve Ma. 02668 05/23/2016 page. Cityrrown 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 Oil 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.): At the time of the inspection there no signs of solids carryover or evidence of past hydraulic failure Pump Chamber(locate on site plan): Pumps in working order: I ❑ Yes ❑ No" Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): "If pumps or alarms are not in working orders stem is a conditional 9 Y d tional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: l Ii t5ins•3/13 f Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M ,•''t 186 Capes Trail Property Address Tim and Deborah Hobill Owner Owner's Name information is required for every West Barnstable Ma. 02668 05/23/2016 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ® leaching galleries number: 7 ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comment$(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): At the time of the inspection there were no signs of past hydraulic failure rk 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 i Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 186 Capes Trail Property Address Tim and Deborah Hobill Owner Owner's Name information is required for every West Barnstable Ma. 02668 05/23/2016 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•3/13 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 186 Capes Trail Property Address Tim and Deborah Hobill Owner Owner's Name information fo is every West Barnstable required for eve Ma. 02668 05/23/2016 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately 3 1 J 3 73 E:-q I 1 T-: L A eTcc} t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ,.•' 186 Capes Trail Property Address Tim and Deborah Hobill Owner Owner's Name information is every West Barnstable required for eve Ma. 02668 05/23/2016 page. City/Town 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: 14 plus feet 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: I augered a hole at a lower elevation and shot it with a transit to show five plus feet of seperation i Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3113 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 186 Capes Trail Property Address Tim and Deborah Hobill Owner Owner's Name required for is every West Barnstable required for eve Ma. 02668 05/23/2016 page. CitylTown 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 re e T N0 d20 t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 e Z-o I 20 TOWN OF BARNSTABLE LOCATION 1 � _( �� t L_ SEWAGE # IS11-- 4-7 VILLAGE T-(7,.. 2�t�:�f-� L�ASSESSOR'S MAP &LOT dad� INSTALLER'S NAME&PHONE NO.j�ScnZt Qx-ez-it ren,1117— - SEPTIC TANK CAPACITY LEACHING FACILITY: (type)--�d�l_L..C� ii2� fsize)�� �� ILA NO.OF BEDROOMS �S BUII DER O OWNER LEIZ� PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) P SCE Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by r c3 17 l0 1 1 s 1 1 i i I I/ Ito / �3 t / 4 J O GJ w Lo� 20 i TOWN OF BARNSTABLE LOCATION QA-. ( SEWAGE # VILLAGE_ 1.(7 _ ¢,�A ;F,t ASSESSOR'S MAP&LO . . � INSTALLER'S NAME&PHONE NO. j-3e IZ cam,_, t (' A S- L i SEPTIC TANK CAPACITYf1Z1 ,,� LEACHING FACILITY: (type) t r t-�•( Ze m )� t NO.OF BEDROOMS�� =BUELDERLOROWNER PERMIT DATE: A, COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and LeachingFacility ty (If any wells exist on site or within 200 feet of leaching facility) :2 � Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) i Furnished by Feet I L � 00 0 i i r .o � No. FEE fh® THE COMMONWEALTH OF MASSACHUSETTS `"I g �3At2NSfiA13LE MASSACHUSETTS �kyyfirativn for Pisposal ,*Votem Guetrurtion jhrrait Application is hereby made for a Permit to Construct(X) or Repair( )an On-site Sewage Disposal System at: Location Address or Lot No. Owner's Name,Address and Tel.No. CLOT 2-0) �* 19,10 CAPES 'C'CZAtL CH�tM��ON 311�L� ; WC.. WEST i3A2s�lSTABLr ,MA 3©o DAL sT� E c, Sv1T t5! PCnng2oY�, MA D23�9 ��'f Ztv $600 Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 130 TOLO'Tjl DOWN GAPE GNvltiEEQkN&\ , tn1G• 1(0 5 wAKE6H RAAQ, M 0G6A 1v1A i N S-f. jAP-1\A0u-r -4 iAA Mn2S-ro�S r 1ILL-5A g39 SOS, -1-1 t q 0,q 5 0 18 — cD2— 4-5 4-1 Type of Building: Dwelling No. of Bedrooms TR Garbage Grinder(90) Other Type of Building No. per Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 3 3 gallons per day. Calculated daily flow 3 5 S 7 gallons. Plan Date Nov•. 2O, 1 q ct s Number of sheets Revision Date l: C Title SIT KwQ Si✓WPi6iE PLAN oc ( I,o-c 2A #[8(p cAprS rt0-AI% Description of Soil c-`E AN W\EDl1J M SALE y j Lo e Gt_E S No y4k(�(L £►.1co�r rc�Efl Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement:+` The undersigned agrees to ensure the construction and maintenance of the aforedescribed on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has ben is abhis and of ealth. l Signed Date 7 6 L 7�` Application Approved by Date Application Disapproved for the following reasons Permit No. `�L�- `� Date Issued �( t� p No. (� r,�x o �� FEE THE COMMONWEALTH OF 4SSACHUSETTS L� 8 T3ARNSTAP,L'E MASSACHUSETTS .. . c4utivition for Disposal *Vstent (gons#rurttan lirrmit Application is hereby made for a Permit to Construct(X) or Repair( ) an On-site Sewage Disposal System at: [1' ocation Address or Lot No. ka Owner's Name,Address and Tel.No. LoT 20� # l to CADL>r T1�At� Ct-AM�A0N i3U%L0',--fL5 1tQC , e� .02 00 ` i• ,R ��iLNSTntSL� MA 3oC) OA\C. sTQ—�E`' Svi r1_ ISS nstaller's Name Address,and Tel.No. + Designer's Name,Address and Tel.No 1 �> t3aRTo�_O-TTI CotvSTQZuC--r\C>r U0WN GAPE_ t_NC7INt'.tZ21N0 t0,7 W/a 1�E�� {ZoA 9 -11�" �, +� r s f ry ••: }ti iF�s"_'_• : '� .i+ ,. a b M.11 t S NVA h� M l r a >-r� a Type of Building. 4 Dwelling o. of Bedrooms TH 2�� Garbage Grinder(90) Other„� t'yr of Building No. per Persons Showers( ) Cafeteria( ) erFixtures '. ;'.. Desi n Flow ��3 C) gallons per day. Calculated daily flow 3 S 3 "� µ galllons•� Plan Date Nov • -).0 , I,n Number of sheets, evlsibn Date _ N �, y. iiiS!'rs:c`i• „yvrf v Title S ITL A N 0 SI=W A G I' P CAf r 'o�" (-i�o cj K-C)� �1�sCo C APE S . Descr p n of Soil' c-\-` NN S4\ND w / C 0 rs 6 ` hto v.l AM(L E N cov t.m=2E p k. Nature of Repairs or Alterations(Answer when applicable) ! l; "� / ✓ J Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the aforedescribed on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to,place the system in operation until a Certificate of Compliance has b en�Asdb is B-and of Realth. / I Signed Date 7—1 L 2 Application Approved by U� �1e4A_%_a4 a Date :;j Application Disapproved for the following reasons Permit No. 9 - L✓ "7 Date Issued �i: 0 :Sk. THErC�OMMONWEALTH OF MASSACHUSETTS '. —MASSACHUSETTS C�>rr#t�t>c�x#.e II� (�IIm�littnce - THIS IS TO CERTIFY, that the On-site Sewage Disposal System installed(,.,o) or repaired/replaced( ) on by .(r for at 4 . ' S` has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. Yl— dated Use of this system is conditioned on compliance with the provisions set forth below: The issuance.of this certificate shall not be construed as a guarantee that the system will function as designed. This Certificate expires on DATE I�F_'01y; > 11" Inspector U THE COMMONWEALTH OF MASSACHUSETTS No. 9-92 / � , MASSACHUSETTS FEE �7 ptsposttl �1s#ent �IIxts#rnc#tIInermt# Permission is hereby granted to to construct( y),or repair( )an On-site Sewage System located at and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. : All construction must be completed within three years of the date below. DATE � "' % Approved by FORM 1255 Re,3/95 A.M.SULKIN CO.-BOSTON,MA r '1 _fit pS p ✓� ` %� ` � pAROEL N0: �..4e, No. ------------- Fee-- ------------------ BOARD OF HEALTH TOWN OF BARNSTABLE Application ArVell Con0ructionPermit Application is hereby made for a,pe it to Construct (`r-)-Alter ( ), or Repair ( )an ain_div,*dgal Wfll at7 Location — Address Assessors Map and Parcel ------------------ ___- - -- ---- f, I�/� Owne ------------Address------------------------ �- <"-----"-------------—---------------------------------------------------- ------------------------------- -------------- Installer — Driller Address Type of Building Dwelling--------------------------------------------------------------- Other - Type of Building------------------------------- No. of Persons-------------------------------------------- Type of Well Capacity_-------------------- — - —- — --— --— Purpose of Well-------- ------- Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation — The undersigned further agrees not to place the well in operation unti a Certificate .of Compliance has been issued by the Board of Health. Signet=(^—^ �---- date _ Application Approved By — - ------ ------- — date Application Disapproved for the following reasons:-- --------------------------- --- ------------------------------------------------------------------------------------ date Permit No. -�'1�� -- Issued-- `- ------ ---------------- date BOARD OF HEALTH TOWN OF BARNSTABLE (Certificate Of Compliance THIS S/TO_5E,RTIFY, hat the Individual Well Constructed (4, Altered ( ), or Repaired ( ) by �1 �✓l -- "------- —— ------- --- - iller at 7`�`5�__ d `�!` : --� ( 4l ----- - - --------- 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 rY�'"- � �Dated THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE --- ---— - --------- ---- Inspector--------------------------------------- a,1•riL�''�"���'�wl�rr..,IM SFr�N� ,�+�*t �"�+ 1�.6�.!"''`;�tr'�'^A'v.��-''.T•T.�CIM"'�,.�yr,�!'-•tiM.�rPl;trrv...y�..� r +•,try y 01 ,,. No.- -tree--tree - -------------- BOARD OF HEALTH F TOWN OF BARNSTABLE i Application for'Veif Con6truction3permit Application is hereby made for a pelmit to Construct (�-)'-Alter ( ), or Repair ( )an indite dual W 11 at 0&_f7t7go-------- � --= � tree=tree s` --A0___—cy� !-'- -' Location — Address Assessors Map and Parcel. — _M — Owne? — — Address ----------------------------- Installer Driller 9 Address f IF, Type of Building Dwelling ) . ------- -------------------- ----------------------tree--tree ° Other - Type of Building--------------------------------- No. of Persons----------------------------------------------- Ir Type of Well Capacity---------------------- - -- -------------------tree_--_ Purpose of Well------ - -- -- ------tree---- 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 unti a Certificate .of Compliance has been issued by the Board of Health. r Signed � �� -- f ate Application Approved By - tree-- •"�-ram i date Application Disapproved for the following reasons:------------------------------------------------_-__---------------___________-____. - -tree tree tree-- tree — tree - - -tree ---------------- -- ` date _7 Permit No. - ' =- — Issued--- 7`-- - - -- date i BOARD OF HEALTH TOWN OF BARNSTABLE C ertif irate Of Compliance THIS S TO ERTIFY, That the Individual Well Constructed (4, Altered ( ), or Repaired ( ) byI ' -- 'r- -------- ------------------------ -- -----------------------------------tree--tree --------------- --------------------- I staIler atLahas 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 -- ` -���•' -Dated THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE----------------------------------------------- —- -- Inspector--------------------------------------------------------------- BOARD OF HEALTH TOWN OF BARNSTABLE Vell Construct ion pefmit ` .No. --tree-tree Fee-�1- ----tree---- Permission is hereby granted J-A - --` ^tree---tree--- - - - - ----------------------------- j to Construct (-/,), Alter ( ), or Repair ( ) an Individual Well / No. --------------- tree- tree tree tree— - tree tree- -tree -— - - - - - --- --� ---- � Street ]- _ _ y..�tree - tree �- as shown �on the application for a Well Construction Permit - Dated-- - - ---- 11 ---- -------------------------------- ----- Board of Health DATE a' DepartmPiifSf Environmental Management/Division of Water,Resources. ,# WELL COMPLETION REPORT WELL L r C TION, 0 GEOGRAPHIC DESCRIPTION' Address IL' N'U5+ E W, of Antis � �r k(Ieetl �irclpe) City/Town— Well /l �" 1 AAF, owner/W � 16 ) (road) Address ✓N""� •[�� N S ...W ,of'. (nil.in tenths) (circle) intersect. Board of Health permit obtained: yes ❑ no❑ (road) WELL US WELL DATA Domestic Public❑ Industrial ❑ Totel well depth Monitoring❑ Other Depth to bedrock-� Water-bearing rock/unconsolidated material: Method drilled KoThAy Date drilled �� f cat Description Water bearing zo :es: t CAS. 1) From To t � Type 2) From To . Length 0 ft. DiaLLkh D�� _ in. 31 From To Length into bedrockhft. Gravel pack well: dia. Protective well seal: Screen: d'a isIkIp Grout_❑ Other. Slot�I length,/b from * to STATIC WATER LEVEL(all wells) . Static water level below land surfacel3o ft. Date fQ WELL TEST,(production wells) farawdown`f ft. after pumping _hr � m atgpm How.measurep'�-r Recovery it.''after—hr. min LOG of FORMATIONS COMMENTS Materials rs To o Drille 4 t.r gt+ 0 v . 4; t o . "Firm o Address r O 16.. City/Town t It 150 oz 'Supervising Driller Regal r A i nature of supervising registered well drifter.. Phrase Print►irmlr - 13OA.RD OF HEALTH COPY ' ENVIROTECH LABORATORIES, INC. MA Cert. No.: M-MA 063 449 Rte. 130 • Sandwich, MA 02563 (508)888-6460 . 1-800-339-6460 FAX(508) 888-6446 CLIENT: Champion Builders LOCATION: Lot 20 Caper Trail ADDRESS: W. Barnstable, M SAMPLE DATE: 1-30-96 DATE RECEIVED: 1-30-96 Ci�LLFCTF'D BY: L. Wi.le & Son. ._ LAB I.D. #• E1252 TIME: N/A JOB TYPE: New Well SAMPLE I.D. #: E1252 WELL SPECS. : 160' 4" PVC 10 G.P.M. RESULTS OF ANALYSIS: Parameters Units Recommended Result Limit Coliform bacteria/100ml (MF Method) 0 0 H pH units 6.0-8.5 5.62 p umhos/cm 500 547 Conductance 28.0 81.0 Sodium mg/L 0.43 Nitrate-N mg/L 10.0 Iron mg/L 0.3 0.09 0.05 0.009 Manganese mg/L Hardness mg/L as CaCO3 500 .1 50 Sulfate mg/L 50 9.31 1.2 2 Potassium mg/L 9 200 1 Alkalinity mg/L 250 14.0 Chloride /L 66.5 5.0 4.0 Turbidity NTU _ Color APC units 15.0 LT i.G Volatile Organics See attached report. EPA #601/602 ug/L None detected. COMMENTS: Low pH indicates high corrosive characteristics. Sodium level is not a health hazard, but if on a low sodium diet consult a physician before drinking. Yes No WATER IS SUITABLE FOR DRINKING PURPOSES FOR PARrETERS TESTED. XXX Date 66 "aldJ- ri LT = Less Than rector GRD[lIVDVI�ATER, EPA METHODS 601 and 602 AnrALYrjcac. Volatile Organics (GC/PID/ELCD) Lab ID: 12668-01 Field ID: E1252 Batch ID: VG3-0502-W Project: Champion/Lot 20 Capes Way Sampled: 01-30-96 Client: En,virotech Received: 01-30-96 Cont/Prsv: 40mL VOA Vial/HCl Cool Analyzed: 01-31-96 Matrix: Aqueous CONCENTRATION REPORTING LIMIT PARAMETER ( g/ (u9/L) thane BRL ' . 5 Dichlorodifluorome BRL : 5 Chl prom .t,an a - BRL 5 Vinyl Chloride BRL 5 Bromomethane .- BRL I Chloroethane , . BRL 1 Trichlorofluoromethane BRL 1 1,1-pichloroethene BRL I Methylene Chloride BRL 1 trans-1,2-Dichloroethene BRL I 1,1-Dichloroethane BRL 1 cis-1,2-Dichloroethene * BRL 1 Chloroform' BRL I 1,1,1-Trichloroethane BRL 1 Carbon Tetrachloride BRL 1 Benzene BRL 1 1,2-Dichloroethane BRL 1 Trichloroethene BRL• 1 1,2-Dichloropropane BRL 5 Bromodichloromethane BRL 1 2-Chloroethyl Vinyl Ether BRL 1 cis-1,3-Dichloropropene BRL I Toluene BRL 1 trans-1 ,3-Dichloropropene BRL 1 1,1,2-Trichloroethane BRL 1 Tetrachloroethene BRL 1 Dibromoc.hloromethane BRL 1 Chlorobenzene BRL 1 Ethylbenzene BRL 1 meta-and para-Xylene * BRL 1 ortho-Xylene * BRL 1 Bromoform BRL 1 1,1,2,2-Tetrachloroethane BRL 1 1,3-Dichlorobenzene BRL 1 1,4-Dichlorobenzene BRL 1,2-Dichlorobenzene ME ASURED RECOVERY QC LIMITS QC SURROGATE COMPOUND SPIKED 87 _ 113 a,a,a-Trifluorotoluene 3o 29 30 27 90 %95 % 83 - 117 1,2-Dichloroethane-d4 - BRL - Below Reporting Limit. * Non-target compound. Method Refere Ances: Method 601 - Purgeable Halocarbons and Method 602 - Purgeable Aromatics, 40 C.F.R. 13 Appendix . t SEPTIC PROFILE TEST HOLE LOGS T.O.F. AT EL (WOT TO SC L.E� — • ACCESS COVER TO WITHIN Ir OF FIN. GRADE ACCESS COVER (WATERTIGHT) TO ENGINEER:_ -"C��'�'UL yGC1 'G= 42 E s � N Ir of Fly. GRADE for r MINIMUM .75' OF COVER OVER PRECAST 75'so 2X SLOPE REQUIRED OVER SYSTEM > WITNESS: -zq_ RUN PIPE LEVEL I -- r -- / . cDATE: f SG (Da_) FOR i1RST 2' 3 _ _-__-- ___ __ y�' PROPOSED /l;>` L % r y �.,/ ( i �� " GALLON SEPTIC ,r, IN _—� t, - /S' P E R C. RATE - -- --- _ / A TANK (H_) � �— , _ --- �/�'3 ¢�. ::_cam _ CLASS _�`"` SOILS # pJ`� -5 ? 7 — — - _ _ ----- f -- - 1 Nr / (-I SLOPE) CRUSHED STONE OR MECHANICAL `�" t � '~ '� �/ �� ��` ��� � o DEPTH OF FLOW 4 COMPACTION. (15.221 [2]} - — �� cr TEE SIZES; �X SLOPE) (.,X SLOPE) INLET DEPTH - OUTLET DEPTH - LOCATION MAP (47 ! ' , -- — /5Z.`� ASSESSORS MAP �e�--- PARCEL _ �� FOUNDATION— `? SEPTIC TANK ----5� --�-- -- ---- D' BOX — LEACHINC FACILITY ✓,, L - `I FLOOD ZONE _ I -7 � % -i,W, BUILDING ZONE: -___-- SETBACKS: FRONT - � SIDE - W/Cr's'G REAR 1 1 iPLAN REFERENCE: L-- NOTES: y 1 . DATUM IS " 2. MUNICIPAL WATER IS SEPTIC DESIGN: (GARBAGE DISPOSER IS y _ �/U ter, 3. MINIMUM PIPE PITCH TO BE 1/8" PER FOOT. DESIGN FLOW; BEDROOMS (-__ GPD) = GPD 4. DESIGN LOADING FOR ALL PRECAST UNITS TO BE AASHO-H U___. USE A "{ GPD DESIGN FLOW T w. -- 5. PIPE JOINTS TO BE MADE WATER,IGHT. 5EITtC TANK: ___ GPD (___) _ '_' GALLONS 6. CONSTRUCTION DE-TALS TO BE IN ACCORDANCE WITH MASS. Y J ?� ENVIRONMENTAL CODE TITLE V. �� USE A Z �'' GALLON SEPTIC TANK 7. THIS PLAN IS FOR PROPOSED WORK ONLY AND NOT -TO HE _ LEr�CHING: USED FOR LOT LINE STAKING SIDES: 1f 1____ (-' ) _ '�l GPD 8. PIPE FOR SEr'TIC SYSTEM TO SCH. 40-4' PVC, L� F s x = .?c ( 7 = --- GPD BOTTOM: _.�...._ -- __) ____ OR CONCEALED WITHOUT 9. COMPONENTS NOT TO BE BACKFILLED /, t- �,---} TOTAL: `r S.F. _ G INSPECTION BY BOARD OF HEALTH .AND PERMISSION OBTAINED ---- -- �� FROM BOARDF HEALTH. X _ ti I� t r Gy rstGt! r t c a ,a, F✓1.4-r`c,2 l_ G GC c 4�,lTC'F: 77 L� t ✓ P—L P, 4,- `�f E W IT N Q rat is A L L-r—"t kjG- \- \. j �-.�.% .'.%-L'J�T .'�..cc::�F�iB c 1 SITE _ �T SEWAGE PLAN Off, AND 1 ': ..�� '`\,"`''`."_._-�' ►...'%_. _� ,`` � � �' � y`. '�, .----. ,��-- •— �,Yc.' .'.. 'T':". C,-..!_ ''f'�`:i :... j__�.f�5 ( �° t 4 / E OF HEALTH, . rSGX! HOARD `7 �- I - �, �, l�A PREPARED FOR: I 1 , /:57 ; _ �4y PR 77 APPROVED DATE - - 3 v (ad .,Feat -'. F n , / �(r 1 SCALE, DATA,- �/J � , down Gape engineering inC. "��''" 2s'�s n >tE Ir�RN r �a H. �J iF WADI `r' - -• `' NGIN�.ERS 1 '—�- � CIVIL E � C�1AL,4 ,- 3 a�t� LAND SURVEYORS a tw, " ---_� ` PHONE 508-362 4541 /Z G� L 2!. 55 i" FAX 508-362-9880 --- /U 777,e �-I/_I _. - 3e main s armou , ma H. OJALA, S. DATE - - - -