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0651 MAIN ST./RTE 6A(W.BARN.) - Health
651 Main St Burnley Nemwqq§ymd 156-057 West Barnstable 4 r, i i L No. 4210 1/3 BLU Lr-ksO H d Cqj eaaO 10% (s ® ® ® O f Yj/ Fee 3 100 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yew PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 9pplitAtlon for MisposAf 6pstem Construction 3permit Application for a Permit to Construct( ) Repair( ) Upgrade tk) Abandon( ) ❑Complete System ©Individual Components Location Address or Lot No. WoO M&,n Stct*k- Owner's Name,Address,and Tel.No. (ler 6 t1 Ff pn f3pr,ti Wes} �atna�gbl¢� Assessor's Map/Parcel 1Sto II . (o6O Mohr` Sk W.UprnS}Ablt, 50$• uZ. %J93 Installer's Name,Address,and Tel.No. rC,x(;oalo.'�an 1nt• Designer's Name,Address,and Tel.No. 00wo �V4 Rou�c, 1'S0 Sandai�c,►> Sog• ���•0653 959 mo�in S� AtMookv, Sot. 3b2. 4S41 Type of Building: DwellingNo.of Bedrooms Lot Size 4S 00o t , sq.ft.- Garbage Grinder(WO) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) Z2.0 gpd Design flow provided 2Z. •C1 gpd Plan Date 11-I q 'Z 1 Number of sheets I Revision Date Title Size of Septic Tank ftAGbt►nq 1000 gallon Type of S.A.S. 15 Skondo►c& W4%ra,61S 33.Z6 X 20.5 Description of Soil $ee 01 DAa Nature of Repairs or Alterations(Answer when applicable) I ASkh on nE ntw pump rnn e.r np d SAS Co.nna.c nj k-o exi5};n k0o0 !�Okton SIT. Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signe Date 3 u Z2 Application Approved by Date Application Disapproved by Date for the following reasons Permit No. Date Issued pppV • a '\„r ,yd� .f+ Ar:.A AMiP'N FrtA '. Y `•riM• '�a °{''4,41 No. ''1 { R Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Y4_._ es PUBLIC HEALTH DIVISION - TOWN OF. BARNSTABLE, MASSACHUSETTS application for -Misposal *pstent Construction Permit, t Application for a Permit to Construct.( Repair( ) pgradeex).Abandon( ) ❑Complete System ❑X Indi idual Components Location Address or Lot No. to `)A r c e.\ Owner's Name,Address,and Tel.No. Assessor's Map/Parcel 4,5{o t r s t U 0 '"1 n v n �,( l.5. :mac n`��C, 1 e 50 ? Installer's Name,Address,and Tel.No. $d `,Y,cr do F,t3n IA(- Designer's Name,Address,and Tel.No. Vows yy' '37k`I t�c�ulc i�Q SQ�ct+. .(1, <�OZ• '-111 .00,53 9159 mcvc) h i Type of Building: Dwelling No.of Bedrooms M Lot'Size LIS, 004 'sq.ft.l- Garbage Grinder(Vo) Other Type of Building No.of Persons Showers( ) Cafeteria( y Other Fixtures Design Flow(min.required) 2 L 4 gpd Design flow provided %Z.q gpd, Plan ' Date 1 t q 1.t " Number of sheets 1 Revision Date,—09l f 61;� Title Size of Septic Tank cr✓x t+nu W00 (\C#Mc;r� Type of S.A.S. 15 `)�antt �d tl' 11 r,a1 r,r S 3-1.Z; Description of Soil Sec �1 tans' ram, Nature of Repairs or Alterations(Answer when applicable) v�necf�� Date last inspected: ' �. Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signed rr Date Date J5WG c3-, _Application Approved by � ,,�.•� -.. Application Disapproved by V Date ' for the following reasons f - Permit No. S. �1 r' i Date Issued / —�^✓� ------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( ) Upgraded( K) Abandoned( )by at (v0 ��G+ t_;�f=c 4l l has been constructed in accordance r / ) with the provisions of Title 5 and the for Disposal System Construction Permit Ngw`1`? ' 1. 5 dated f ✓ -.�- Installer Q) mva'w,, k a . Designer n v #bedrooms Approved design flow gpd The issuance of this permit shall not be construed as a guarantee that the system will funcrion as designed. Date C� Inspector .- r No:- ;=- :-'" 1 Fee 40G - THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS ` 4 .e 4 1 -_ Misposal *pstrm Construction 3permit Permission is hereby granted to Construct( } Repair( ) Upgrade(X Abandon( ) System located at (:)(,0 Oln+n st C e e E (A and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permit. Date 6A04> Approved by .�,, TOWN OF BARNSTABLE [INSTALLER'S CATION LGO (n a,r\ 5J, SEWAGE# ZOZZ- /S5' LLAGE LJ. Boxn ASSESSOR'S MAP&PARCEL IS I It NAME&PHONE NO. B Q E XCvwo.-�i o� U��•-0G53 SEPTIC TANK CAPACITY LEACHING FACILITY:(type) Ty, 'J4r,:x4or5 /551ati(size) Zo x 33 NO.OF BEDROOMS Z "-&ed n4-ntle) OWNER Mcrr 11 �. C ca.n �o.v►5 PERMIT DATE: S-ZO • ZZ COMPLIANCE DATE: ' )S'4 2 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 At- ia,lo„ AZ 3z -y° A3- Z-71y 33' 33 ' A Ay• 32 ' 04 Q (DAS �.i�vf�l g y B s i Town of Barnstable ;00A of Health 200' lain Street, Hyannis MA 02601 16S9. Office: 508-862 4644 John Norman,Chairrman FAX: 508-790-6304 Donald A.Guadagnoli,M.D. F.P.(Thomas)Lee,P.E. Daniel Luczkow,M.D.Alt. Mr. Daniel Ojala, PE, PLS March 3, 2022 Down Cape Engineering Inc. 939 Route 6A Yarmouthport, MA 02675 RE: 660 Main Street, West Barnstable A = 156-011 Dear Mr. Ojala, On September 2, 2021, you submitted several variance requests concerning a proposed onsite sewage disposal system at 660 Main Street, West Barnstable. The Board of Health held a public meeting on September 28, 2021 at 3:00 p.m. to hear and review the variance requests. During the public meeting, the following variance was not granted from the State Environmental Code, Title V: 310 CMR 15.405 (1): To install a soil absorption system three (3) feet above the perched groundwater table, in lieu of the five (5) feet minimum separation distance required. The following variances were granted from local and State regulations: 310 CMR 15.405 (1): To install a soil absorption system four (4) feet above the perched groundwater table, in lieu of the five (5) feet minimum separation distance required. 310 CMR 15.415 (2): To allow 3.1 feet of naturally occurring pervious material beneath the leaching area. Section 397-8 (E) of the Town of Barnstable Code: To install a soil absorption system 109 feet away from an onsite private well, in lieu of the 150 feet minimum separation distance required. These variances were granted with the following conditions: 1. The engineering plan shall be revised to show four (4) feet of soil separation above the perched groundwater table. Q:\WPFILES\Ojala 660 Main Street West Barnstable Septic Variances Sept 2021.docx 2. The engineering plan shall be revised to show the cover to grade over the Zabel filter. 3. The designing engineer shall submit sieve analysis results. 4. No more than two (2) bedrooms maximum are authorized at this property. Dens, study rooms, offices, finished attics, sleeping lofts, and similar-type rooms are considered "bedrooms" according to the MA Department of Environmental Protection. 5. The applicant shall record a properly worded deed restriction, signed by the owner of the property, at the Barnstable County Registry of Deeds restricting the property to two (2) bedrooms maximum. A copy of the recorded deed restriction shall be submitted to the Health Agent prior to obtaining a disposal works construction permit. These variances were granted because the physical constraints at the site restrict the location of the septic system components due to private drinking water well and wetlands in the area. Sincerely J III n Norman Chairman Q:\WPFILES\Ojala 660 Main Street West Barnstable Septic Variances Sept 2021.docx Bk 15467 P925 JWL70099 ` - ► 8-13-2002 a DEED RESTRICTION j i We, Merrill H. Davis & Frances J. Davis, Husband & Wife, both of 660 Main Street, West Barnstable, Massachusetts 02668, as owners of property located on Route 6A (660 Main Street) in West Barnstable, Massachusetts 02668 as Tenants by the Entirety,.which property is more completely described in a deed from Richard D. 4 Johnston and Nancy E. Johnston to us dated July 3, 1978 and recorded with I Barnstable County Registry of Deeds at Book 2741 Page 267 do hereby restrict the use i and occupancy of the existing dwelling property and any future structures to no more j than two (2) bedrooms. f This Deed Restriction is to run with and become appurtenant to the property. This f I Deed Restriction is placed upon the property consistent with the requirements of a I Variance issued by the Town of Barnstable Board of Health dated May 29, 2002, permitting the construction of a Title V septic system on the property with certain f t i i variances. , i i f i For Title; See deed dated July 3, 1978 and recorded with Barnstable County Registry of Deeds at Book 2741 Page 267. i I C i f Bk 15467 P926 T70099 i i WITNESS Our Hands and Seals this r� Day of 2002. FIX F ' I erriI H. D vi �� Frances J. Davis COMMONWEALTH OF MASSACHUSETTS 7 Barnstable, ss , 2002 Then personally appeared the above-named Merrill H. Davis and acknowledged the foregoing to be his free act and deed. before me, `t`tgljfiUNtHf fp%�f.. OBy,n^Q I e� •�s 4�' No Public ; ;r :.j •�' M C mmission Expires: ELIZABETH S.CALLAHAN NOTARY PUBLIC My Commission Expires Jan.7,2005 �.� COMMONWEALTH OF MASSACHUSETTS Barnstable, ss , 2002 Then personally appeared the above-named Frances J. Davis and acknowledged the foregoing to be her free act and deed, before me, No Public M mmission Expires: e\mjp\re\Davis\ddrestr ELI ABETH NOTARY,CAL AHAN <19i11 f f t�J" My Commission Expires Jan.7,205 1 fir✓ 44 rS �,.•.;ITS r>•ti? '.fin`'• ,•o.+ '' '�� �.._ i ld/lfJlllt111i1t1\��1\ l E I BARNSTABLE REGISTRY OF DEEDS i EXCERPT FROM THE BOARD OF HEALTH MEETING MINUTES ON 9/28/21: I. Variances —Septic: - A. Daniel Ojala, Down Cape Engineering, representing Merrill Davis, owner—660 Main Street, West Barnstable, Map/Parcel 156-011, 45,000 square feet parcel, requesting three variances and a pump chamber. Mr. Ojala presented the septic plan and had a revised.plan showing a filter for outlet on tank. Mr. Norman said that outlet will require cover to grade so the owner can service the filter. Mr. McKean brought up that the staff would like something from Brian Dudley if engineer wanted to use 3 feet separation without an Innovative/Alternative (I/A) system. Mr. Norman and Mr. Lee stated they would prefer the four foot separation as the perch level is constantly shifting and the effluent may go into the perched area and run into wetlands. They agreed it does not call for a strip-out. Upon a motion duly made by Dr. Guadagnoli, and seconded by Mr. Lee, the Board voted to grant the variances as presented with the following conditions: 1, a 2-bedroom deed restriction is required, 2) revise plan with a four foot separation from system to groundwater which includes 3.1 naturally occurring pervious material and the system will have an approximate one foot mound, 3) remove variance for 15.415 of separation to groundwater,( add sieve analysis, and(5 filter cover to grade so serviceable. (Unanimously, voted in favor.) Q:\MINUTES\EXCERPT OF MINUTES\EXCERPTS\Excerpt BOH Sep 28 2021660 Main St WB.docx r EXCERPT FROM BOARD OF HEALTH MEETING MINUTES ON 9/28/2021: I. Variances—Septic: A. Daniel Ojala, Down Cape-Engineering, representing Merrill Davis, owner— 660 Main Street, West Barnstable, Map/Parcel 156-011, 45,000 square feet parcel, requesting three variances and a pump chamber. Mr. Ojala presented the septic plan and had a revised plan showing a filter for outlet on tank. Mr. Norman said that outlet will require cover to grade so the owner can service the filter. Mr. McKean brought up that the staff would like something from Brian Dudley if engineer wanted to use 3 feet separation without an Innovative/Alternative (I/A) system. Mr. Norman and Mr. Lee stated the would refer the four foot separation as the r Y p p perch ch level is constantly shifting and the effluent may go into the perched area and run into wetlands. They agreed it does not call for a strip-out. Upon a motion duly made by Dr. Guadagnoli, and seconded by Mr. Lee, the Board voted to grant the variances as presented with the following conditions: 1) a 2- bedroom deed restriction is required, 2) revise plan with a four foot separation from system to groundwater which includes 3.1 naturally occurring pervious material and the system will have an approximate one foot mound, 3) remove variance for 15.415 of separation to groundwater, 4) add sieve analysis, and 5) filter cover to grade so serviceable. (Unanimously, voted in favor.) Town of Barnstable oF11HE Regulatory Services Richard V. Scali, Interim Director H^ MAS& �. r Public Health Division Ar 1639. 01 Thomas McKean,Director BD MA'S 200 Main Street,Hyannis,MA 02601 Office: 508-8624644 Fax: 508-790-6304 Homeowner Certification Form for Alternative Svstems Property Address: &I—e �� � ,-�c y� , le d77igo7 z4F Assessor's Map\Parcel: m � parczI I Property Owners Name: � ����// /�� Gc �•`S In accordance with Massachusetts DEP alternative system approval letters, the following certification information is required by the Owner of record. The Owner of record must place an 'Y' in the applicable box next to each line certifying the information. Yes N\A ❑ I have been provided a copy of the Title 5 I/A technology Approval letters. (15 page Standard Conditions letter and the specific technology letter) ❑ I have been provided with the Owner's Manual i ❑ I have been provided with the Operation and Maintenance Manual ❑ For Systems installed under a Remedial Use Approval, I agree to fulfill my responsibilities to provide a Deed Notice as required by 310 CMR 15.287(10) and the Approval V ❑ For Systems installed under a Remedial Use Approval, I agree to fulfill my responsibilities to provide written notification of the Approval to any new Owner, as required by 310 CMR 15.287(5) ❑ If the design does not provide for the use of garbage grinders, the restriction is understood and accepted ❑ Whether or not covered by a warranty,I understand the requirement to repair,replace, modify or take any other action as required by the Department or the LAA, if the Department or the LAA determines the System to be failing to protect public health and safety and the environment, as defined in 310 CMR 15.303 I , 44 a 7A�::, a agree to comply with all terms and conditions above. Property Owners printed name 0 Property Owners Signature Da Note: This form must be submitted along with the septic system disposal works permit application for all I\A systems including new construction, repairs\upgrades, with and without aggregate (stone) and with conventional design criteria or credited design criteria. Town of Barnstable ME'0`y�p Inspectional Services twaTL g Public .Health Division HA� � Thomas McKean,Director l�D 4 200 Main Street;Hyannis,MA 02601 Office: 508-962-4644 Fax: 508-790-6304 Installer& Designer Certitication Form Date: CJ Sewage Permit# Z 022 155 Assessor's Map\Pareel 15Lo l Designer: bo,Nn C".Q. D'IM it UP l Installer: Y3 �r3 �XL��u LL Address: q3°I iZ (A� J Address: I �-j Tec3o-e q�� Vaml o -fin. P0r4 M6 On 5 ace a a kc aUw was issued a permit to install a (date) (installer) septic system at 0 1( Y1 � 1J11 rn S f i U11 based on a design drawn by (address) (l Y11 N, W121A K p LS dated 5 QLU av a a (designer) ' certify that the septic system referenced above was installed substantially according to � the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. Strip out (if required) was inspected and the soils were found satisfactory. i i I certify that the septic s steml referenced,above was installed with major changes,.(i.t✓. greater than 10' lateral relocation of the. any vertical relocation.of any-component of the septic system) but in accordance .6th'State&Local Regulations. Pldnn revision or certified as-built by designer to follow: Strip out(i£required)was inspected°and he oils were found satisfactory. I certify that the system referenced above was constructed i e with the.to rms of i y `za. s the RA approval letters(if applicable) �4 OANIELA: r � QJAIA- v: CtVIL ' (Installer's Signatu ) No,465M2, dfi �r"tSTt:�W t�� (Designer's Signature) (Affix Designers Stamp Here) I PLEASE RETURN TO BARNSTABLE,PUBLIC HEALTH DIVISION,CERTIFICATE � OF COMPLIANCE WILL NOT,.BE_ ISSUED-UNTIL BOTH.THIS .FORM.,AND AS', BUILT CARD ARE RECEIVEDBYT E BARNSTABLE PUBLIC HEALT�H`,DIV'ISION. THANK YOU. WoaWeptAHEALTMEWER connecASEPTIODesigner Certification rorm.Rov 6.14.13.DOC ` TOWN 9F BARNSTAB E �fY L��Ck'fTiN SEWAGE # VILLAGE.,_WS54'-- flee 0&5iai fe ASSESSOR'S MAP & LOT '°955 nn S��l•2o/v INSTALLER'S NAME&PHONE NO. �bc� rg r��J2) . Gt IVi)�a SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size),SZ X 201 •.$' NO.OF BEDROOMS 7 AA BUILDER OR OWNER #4 Y' SSo PERMIT DATE: �S"� �' vim' COMPLIANCE DATE: .} t Separation Distance Between the:. Maximum Adjusted Groundwater'Table and Bottom of Leaching Facility N19 GAJ 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. c lity) / 1 D Feet Furnished by_ ' t � d� P 0 e . r Io {N,!. .s�i.�'�l�i� - _ - y`L Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes 0- PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 'A Z(pplication for Mig ogaf * gtem Construction Vermoit AOApplication for a Permit to Construct( )Repair O Upgrade( )Abandon( ) ,vomplete System ❑Individual Components Location Address or Lot No. 1;51 f-r 6,4 wner's Name,Address and Tel.No. 9141 Ac�e;cT Svv/2 Assessor's Map/Parcel ��"� ���" �J09 a Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. u- S/YBAN .S�bit S�iAv! 9 �5i 54AAD AhOwicb ?-0/0 J'°3.3 2 .7 Type of Building: Dwelling No.of Bedrooms -7 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building Sme le-r-AN7 . No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow '��7b gallons per day. Calculated daily flow 7 7e) gallons. Plan Date 3 6 6 —OU Number of sheets / Revision Date won e Title Size of Septic Tank ;ZOdca Type of S.A.S. Yr—e, Description of Soil Se 0 Nature of Repairs or Alterations(Answer when applicable) ��� ��X e t, Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been i by s B and of Health. Signe Date '^ Application Approved by Date Application Disapproved for the following reasons 77-- PermitNo. j Date Issued ij - '" "� r �`ia•_� ! Fee Entered inscom uter> THE COMMONWEALTH OF MASSACHUSETS _ p Yes r�t. 1 - - PUBLIC HEALTW&VISION -TOWN OF_BARNSTABLE, MASSACHUSETTS =� ,{3 rication for Oig ool otem Con6truction Permit Application for a Permit to Construct( )Repair(/)IIp'grade O Abandon( ) .,VComplete System ❑Individual Components W Location Address or Lot No. 4-51 orf 7 61 A r wner's Name,Address and Tel.No. Assessor's Map/Parcel i Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 744e,) /of •SAri1-774,4c S��v/cam- ��C_ C"V",�ec_h ,Z 0/0 r33 a 77 Type of Building: Dwelling No.of Bedrooms 7 Lot Size sq.ft. Garbage Grinder( ) " ,.Other Type �i of Building S/4g/t I; . No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow -__.7 17d. gallons per day. Calculated daily flow 770 -'` gallons. 4: Plan Date 3 — 60 Number of sheets / Revision Date /V06 @. Title Size of Septic Tahk Zoso Type of S.A.S. i Description of Soil see )D N Nature of,Repairs or Alterations(Answer when applicable) Date fast inspected:. Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage"disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operatiowuntil a Certifi- cate of Compliance has been by t s d of Health. i Signed- Date 4 T Application Approved by Date E Application Disapproved for the following reasons i t 'Permit`N�o. l Date IssuedS ------�— .., -=---;�---------r-- --------- THE COMMONWEALTH Of-MASSACHUSETTS \ \ BARNSTABLE, MA!i�'A,CHUSETTS Certificates,f Compliance THIS IS TO CERTIFY, that the On-site'Sewage Disposal System Constructed( )Repaired (.k' Upgraded( ) Abandoned( )by 250u -%iQld SOWiT�oe_ < at �45 /�7 6 has been constructed i ccordance with the provisions of Title 5 and e for Disposal System Construction Pe PMP r dated L Installer v S + ./ Designer n ra The issuance of this permit sh, not b c strued as a guarantee that t e s -w l funatio ash esig Date Inspector I ! 0 - -------------------- *i - No. r C r Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE,. MASSACHUSET T Mi!6poga[ &pgtem Construction Permit Permission is hereby granted to Construct( Repair(X)Upgrade( )Abandon System located at s/ ��R ��/ti ST �` �✓ / 9s%!�/L/ and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of �t. Approved by�' � 'Date: z ��� p �U/'sIG6- n'1-%n0 r 44pJSe TOWN OF BARNSTABLE �r,J�s �9� BOARD OF HEALTH '3 ARTICLE II: MINIMUM STANDARDS FOR HUMAN HABITATION Date 1 el Time: In t�Out S Owner e2ry- Tenant Address 60 S o c Address ern S,6+to Compliance Remarks or Regulation# Yes NO Recommendations 2. Kitchen Facilities 3. Bathroom Facilities 4. Water Supply 5. Hot Water Facilities 6. Heating Facilities 7. Lighting and Electrical Facilities 8. Ventilation 9. Installation and Maintenance of Facilities 10. Curtailment of Service 11. Space and Use 12. Exits 13. Installation and Maintenance of Structural Elements 14. Insects and Rodents 15. Garbage and Rubbish Storage and Disposal 16. Sewage Disposal 17.Temporary Housing 18. Driveway Width 19. Number of Tenants Observed PART II 37. Placarding of Condemned Dwelling; r bu 11,�& 'z: (LA NJ- 6e Removal of Occupants; Demolition Sid Rr 2 �� Number of Bedrooms Number of Vehicles Allowed(max) y�C- Number of Persons Allowed (max) Oi a Person(s) Interviewed Insp or -7 ` Q-` � ",� i �S�-a- i& �� � � If Public Building such as Store or Hotel/Motel specify here ' d oFiIKE TOWN OF BARNSTABLE HEALTH iNSPECTOR's Establishment Name: Date: ge: of y � OFFICE HOURS ^ PUBLIC HEALTH DIVISION 8:00-9:30 A.M. BARNSTABLE. • 200 MAIN STREET 3:MON.-o P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified p 67 A�O� HYANNIS,MA 02601 8-8 -FRi. rFo MPS 508-862-4644 No Reference R-Red.Item PLEASE PRINT CLEARLY FOOD ESTABLISHMENT INSP N REPORT Name Date Type o sec ion Oueration(s) Routine" Address Risk Food Service ction AA Level Retail Previous Inspection Pkj Vr) Telephone Residential Kitchen Date: Mobile Pre-operation Owner HACCP Y/N Temporary Suspect Illness Caterer General Complaint Person in Charge(PIC) Time st 'Breakfa HACCP Other Inspector t:. Each violation checked requires an explanation on the narra iv page(s)and a citation of specific provision(s)violated. Violations Related to Foodborne Illness Interventions and Risk Factors(Red Items) Anti-Choking 590.009(E) ❑ Violations marked may pose an imminent health hazard and require immediate corrective Tobacco 590.009(F) ❑ Action as determined by the Board of Health. Allergen Awareness 590.009(G) ❑ FOOD PROTECTION MANAGEMENT ❑ 12.Prevention of Contamination from Hands ❑ 1.PIC Assigned/Knowledgeable/Duties ❑ 13.Handwash Facilities EMPLOYEE HEALTH PROTECTION FROM CHEMICALS.. ❑ 2.Reporting of Diseases by Food Employees and PIC ❑ 14.Approved Food or Color Additives ❑3.Personnel with Infectious Restricted/Excluded ❑ 15. Toxic Chemicals / FOOD FROM APPROVED SOURCE TIMEITEMPERATURE CONTROLS(Potentially Hazardous Foods) kh ❑4.Food and Water from Approved Source ❑ 16.Cooking Temperatures ❑ 5.Receiving/Condition ❑ 17.Reheating ❑6.Tags/Records/Accuracy of Ingredient Statements ❑ 18.Cooling ❑ 7.Conformance with Approved Procedures/HACCP Plans ❑ 19.Hot and Cold Holding PROTECTION FROM CONTAMINATION ❑20.Time As a Public Health Control ❑ 8.Separation/Segregation%'Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS S ) ❑9.Food Contact Surfaces Cleaning and Sanitizing ❑ 21.Food and Food Preparation for HSP ❑ 10.Proper Adequate Handwashing CONSUMER ADVISORY ❑ 11.Good Hygienic Practices ❑ 22.Posting of Consumer Advisories Violations Related to Good Retail Practices(Blue Items) Total Number of Critical Violations Critical(C)violations marked must be corrected immediately. (blue&red items) Non-critical(N)violations must be corrected immediately or Corrective Action Required: ❑ No ❑ Yes within 90 days as determined b the Board of Health. Overall Rating Y Y � Voluntary Compliance. ❑ Employee Restriction/Exclusion ❑ Re inspection Scheduled ❑ Emergency Suspension C N Official Order for Correction:Based on an inspection today,the items ❑ checked indicate violations of 105 CMR 590.000/Federal Food Code. ❑ Embargo. ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other: 23.Management and Personnel (FC-2)(590.003) This report,when signed below by a Board of Health member or its agent 24.Food and`Food Preparation (FC-3)(590.004) constitutes an order of the Board of Health. Failure to correct violations A=Zero critical violations and no.more than anon-critical violations. F=3'or more critical violations. n =critical violations observed, 25.Equipment and Utensils FC-4 590.005 9 or more non-critical violations=F. ( )( ) cited in this report may result in suspension or revocation of the food B=One critical violation and less than 4non-critical violations 26.Water,Plumbing and Waste (FC-5)(590.006) establishment permit and cessation of food establishment operations. If if no critical violations observed,4 to 6 non-critical violations=B. Seriously Critical Violation=F is scored automatically if: no hot 27.Physical Facility (FC-6)(590.007) aggrieved by this order,you have a right to a hearing. Your request must C=2 critical violations and less thenon-cr ,cal. If no critical water,sewage back-up,infestation of rodents or insects,or lack of n refri eration. 28.Poisonous or Toxic Materials (FC-7)(590.008) be in writing and submitted to the Board of Health at the above address v' tions observed,7 to 8 no itical I tions=C. 9 29.Special Requirements (590.009) within 10 days of receipt of this order. 9 30.Other DATE OF RE-INSPECTION: I ct ignature O t: 31.Dumpster screened from public view Permit Posted o Y N Grease Trap Previous Pumping Date Grease Rendered Y N #Seats Observed Frozen Dessert Machines: Outside Dining Y N IC'yature Print: Self Service Wait Service Provided Grease Trap Size Variance Letter Posted Y N Dumpster Screen? Y N -� Violations related to Foodborne Illness Violations Related to Foodbome Illness Interventions Interventions and Risk Factors(Red Items 1-22) and'Risk Factors(Red Items 1-22) (Cont) FOOD PROTECTION MANAGEMENT t PROTECTION FROM CONTAMINATION PROTECTION FROM CHEMICALS 3-501.14(C) PHFs Received at Temperatures According to 1 590.003(A) Assignment of Responsibility* F 8 Cross-contamination 14 Food or Color Additives Law Cooled to 41°F/45°F Within 4 Hours* 590.003(B) Demonstration of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from 3-202.12 Additives* 3-501.15 Cooling Methods for PHFs 2-103.11 Person-in-Charge Duties Cooked and RTE Foods.* 3-302.14 Protection from Unapproved Additives* 1.8 PHF Hot and Cold Holding `+s Contamination from Raw Ingredients 15 Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41'F/45°F EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each 590.004(F) P 7-101.11 Identifying Information-Original Containers* 2 590.003(C) Responsibility of the Person-in-Charge to Other* 7-102.11 Common Name-Working Containers* 3-501.16(A) Hot PHFs Maintained A[.or Above 140'F* Require Reporting by Food Employees and � � � Contamination from the Environment 3-501.16(A) Roasts Held At or Above 130°F* 7-201.11 Separation-Storage* Applicants* 3-302.11(A) Food Protection* 20 .Time as a Public Health Control __ - 7-202.11 Restriction-Presence and Use* 590.003(F) Responsibility of Food Employee or An � 3-302.15 Washing Fruits and Vegetables 3-501.19 Time as a Public Health Control* Applicant To Report To The Person In Charge* 1 7.202.12 Conditions of Use* 3-304.11 Food Contact with Equipment and Utensils* 590.004(11) Variance Requirements 590.003(G) Reporting by Person in Charge* I Contamination from the Consumer 7-203.11 Toxic Containers-Prohibitions* 'r 3 590.003(D) Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* _ 3-306.14(A)(B)Resumed Food and Reservice of Food* -- REQUIREMENTS-FOR 590.003(E) I Removal of Exclusions and Restrictions I w^Y. Disposition of Adulterated or Contaminated 7-204.12 Chemicals for Washing Produce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS(HSP) Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels* 4 Food and Water From Regulated Sources g Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs* 590.004(A-B) Compliance with Food Law* 4-501.111 Manual Warewashing-Hot Water 17.206.12 Rodent Bait Stations* 3-801.11(D) Raw or Partially Cooked Animal Food and 3-201.12 Food in a Hermetically Sealed Container* Sanitization Temperatures* Raw Seed Sprouts Not Served* 7-206.13 Tracking Powders,Pest Control and 3-201.13 Fluid Milk and Milk Products* 4-501.112. Mechanical Warewashing-Hot Water Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served* 3-202.13 Shell Eggs* Sanitization Temperatures* TIME/TEMPERATURE CONTROLS 3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. 16 Proper Cooking Temperatures for PHFs CONSUMER ADVISORY i; _ 3-202.16 Ice Made From Potable Drinking Water* Concentration and Hardness* 3-401.11A(1)(2) Eggs-155°F 15 sec 22 3-603.11 1. Consumer Advisory Posted for Consumption of 5-101.11 Drinking Water from an Approved System* 4-601.11(A) Clean Utensils and Food Contact Surfaces of Eggs-Immediate Service 145°F 15 sec* : Animal Foods That are Raw,Undercooked or - Equipment* Not Otherwise Processed to Eliminate 590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game- + 4-602.11 Cleaning Frequency of Utensils and Food Animals-155°F 15 sec* Pathogens* Egecti-uinooi 590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces of Equipment* 3-302.13 Pasteurized Eggs Substitute for Raw Shell P 3-401.11(B)(1)(2) Pork and Beef Roast-130°F 121 min* Shellfish and Fish From an Approved Source Eggs* _ 4_-702.11 Frequency r f cesSanitizationEquipment* of Utensils and Food 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 sec* 3-201.14 Fish and Recreationally Caught Molluscan Contact Surfaces of Equipment* Shellfish* - 4-703.11 Methods of Sanitization-Hot Water and 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs "SPECIAL REGl171REMENTS » . "" =p r Z ; 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Stuffing Containing Fish,Meat,Poultry or 590.009(A)-(D) Violations of Section 590.009(A)-(D)in cater- Sources* Ratites-165°F 15 sec* in mobile food,tem and residential 10 Proper,Adequate Handwashing g' �� Game and Wild Mushrooms Approved By 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under Regulatory Authority 2-301:11 - Clean Condition-Hands and Arms* 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to 3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165°F* foodbome illness interventions and risk factors. 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-401.11(A)(1)(b) All Other PHFs-145°F 15 sec* Other 590.009 violations relating to good retail 3-201.17 Game Animals* 11 Good Hygienic Practices 17 Reheating for Hot Holding practices should be debited under#29-Special 2-401.11 Eating,Drinking or Using Tobacco* * Requirements. 5 Receiving/Condition g• g g 3-403.11(A)&(D) PHFs 165°F 15 sec 3-202.11 PHF's Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and Mouth* 3-403.11(B) Microwave-165°F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-202.15 Package Integrity* 3-301.12 Preventing Contamination When Tasting* 3-403.11(C) Commercially Processed RTE Food-140°F* Blue Items 23-30) 12 Prevention of Contamination from Hands Critical and non-critical violations,which do not relate to the foodborne 3-101.11 Food Safe and Unadulterated* 3-403.11(E) Remaining Unsliced Portions of Beef Roasts* illness interventions and risk factors listed above,can be found in the 6 Tags/Records:Shellstock 590.004(E) Preventing Contamination from Employees* 18 Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000 3-202.18 Shellstock Identification* 13 Handwashing Facilities 3-501.14(A) Cooling Cooked PHFs from 140°F to 70°F 3-203.12 Shellstock Identification Maintained* Conveniently Located and Accessible Within 2 Hours and From 70°F to 41°F/45°F Item Good Retail Practices FC 590.000 Tags/Records:Fish Products 5-203.11 Numbers and Capacities* Within 4 Hours* 23. Management-and_Personnel i - :FC-T .003 r-* . 3-402.11 Parasite Destruction* 5-204.11 Location and Placement* 3-501.14(B) Cooling PHFs Made from Ambient 24. Food and Food Protection FC-3 .004 * 5-205.11 Accessibility,Operation and Maintenance Temperature Ingredients to 41°F/45°F 25. Equipment and Utensils FC-4 .005 590.0 4( Records,Creation and Retention with P Within 4 Hours* 26. Water,Plumbing and Waste FC:5 acc �. .0063 Labeling of Ingredients* Supplied with Soap and hand Drying Devices 27. Physical Facility 590.004(J) g g _ _ 7 Conformance with Approved Procedures/ 6-301.11 Handwashing Cleanser,Availability 28. Poisonous or Toxic Materials FC-7 1.008 HACCP Plans 6-301.12 Hand Drying Provision 29. 1 Special Requirements 1.009 3-502.11 Specialized Processing Methods* 30. 1 Other 3-502.12 Reduced-Oxygen Packaging Criteria* I 8-103.12 Conformance with Approved Procedures* I S:590Formback6-2doc *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. r af� r Town of Barnstable °s Inspectional Services Y ! �B'M� Public Health Division 039. AfFbA Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Fax: 508-790-6304 Office: 508-862-4644 AFFADAVIT FOR A BED AND BREAKFAST PERMIT EXEMPTION FORM Name of Bed and Breakfast: ! Vl dL7 ftj2,'1_< Y_i C� Address: Telephone: ' Name of Owner: rn1? L7--i Telephone Number: u As Per 2013 Food Code, State Sanitary Code MA Regulations for Minimum Standards for Food Establishment, Chapter X - 105 CMR 590.001 (C)(1) and can be found on website: https://www.mass.gov/regulations/105-CMR-59000-state-sanitary-code- chapter-x-minimum-sanitation-standards-for-food I attest I am qualified for a Bed and Breakfast Permit Exemption because I meet the following criteria: ❑ Owner Occupied ❑ Available guest bedrooms does not exceed 6 ❑ Number of guests does not exceed 18 ❑ Breakfast is the only meal offered ❑ The owner/operator is responsible for ensuring all consumers of this establishment are informed by statements contained in the published advertisements, mailed brochures, and placards posted at the registration area that the food is prepared in a kitchen that is NOT REGULATED/NOR INSPECTED by the FC-regulatory authority. t Signature of Applicant: Ic Date: - ( / 3U / QAApplication Forms\Bed and Breakfast Exempt 2019.doc cf '1Dw Dates T rN 4F BAR New:A PP lieatton RerneW �r LICENSE APPLICATION ■ncuvsrna�`,: _ v Mass 2Q©1t�I an Street / zansfer ArEp r�;t► Hyanzns, Other 508 8fi2 4674 --► N Busnvi ss MAY OrERa WITHotrr A m LICENSE `0n TxE Px IVHSES me p �' � ' Hohone,# � Name of a pllcarit(corporation Address of applieant/corporatlon Business phone _... D/B/A _ -- Business phone# y- Business location: fps - � = r Business mailing address. �-�- Local:busifid§§1d0ress ,:Local,mailing address �� —=----- - LICENSE TYPE y7 ' ....` .. Annual 5easanaf �-" �. :14 vj dz� ..: .:,( HOURS OF OPERATION. '®r : Mf11A1 .:.F1D#:Jf - Em3 3; ..:�2✓ ` i.f...: � '< ....: ..i ::.... v Local mailing address. :Manager`s.Permanent mailing address Mana er's home hone#: Business phone# "77 g P' - - . jq Name of property owner:: ASSESSOR'S MAP/PARCEL# MAf� ...... ..a::. PARCEL .: 71 List any flammable substance or"hazardous uvastex used in business(specify} :. �T � (50.8) 862 4038, Applicants must contact G tfie Bviilding •Commisigner's office, the``Board of :Hearth office; (-5:08} 8,,62-4644,"rand the appropriate Fire i istrict office to schedule insgeetion Signature of app Ecant `Fo i use only REAL ESTATE TA7fES PAID:IN,FLTI.L PAYMENT AGREEMENT.INEFFECT ON' IS THIS USE PERMITTED WITHIN THIS ZONING DISTRICT?: YES O NO Capacity set 6 Buildin Division•_ INSPECTORS APPROVAL P tY Y 9 Bulldin onin .��__-_ _�.".Date -:.. .._ _ - g2 i g - __.__. Board'of Health Date Wire Date -_ __ Plumbing -.� Gas __: ��_� Date - - Fire Distnet ,- -- - - Date Comments: white.Licensing Authority Canary•Health Division: . Gold.-Building Commissioner Pink•Fire©epartment Crocker, Sharon From: Crocker, Sharon Sent: Monday, October 31, 2005 2:24 PM To: Miorandi, Donna; McKean, Thomas Subject: B&B- Burley Manor We received a phone message for annual inspection at: Burley Manor 651 Main St West Barnstable, MA 02668 508-362-7788 Sheila Bournival called and said they serve a continental bkft. Should I add them to B&B List? 1 COMMONWEALTH OF MASSACHUSE'I'TS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS , b DEPARTMENT OF ENVIRONMENTAL PR ,TE O- 1r�IVED JUN 0 2 2003 TOvvw OF BARNSTABLE HEALTH DEPT. TITLE 5 OFFICL-XL INSPECTION FORNI -NOT FOR VOLUNTARY ASSESStiIENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A f CERTIFICATION Property Address: 2 Owner's Name: or 4-k y ,Tone S Owner's Address: MAR � .T . Date of Inspection: PARCEL Name of Inspector: (elease print) - Company Name:_ W1/10 Mailing Address: o t3o� /ozg� -Gffk7a Telephone Number: _ CERTIFICATION STATENIENT 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 SSatioa 15.340 of Title 5(310 CivIR 15.000). The system: !/ Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails a Inspector's Signature: ma d,— Date: The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) %yid& 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. Notes and Comments ****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. IL Page 2 of l 1 r , OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A /� CERTIFICATION (continued) Property Address: ( s� �+ 61 6 S2 Owner: E?S Date of Inspection: 0 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. Sy Passes: have not found any information which indicates that any of the failure criteria described in 310 CNIR 15.303 or in 310 CNIR 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 repaired.The system,upon completion of the replacement or tt air as a be replaced or p approved by the Board of Health,will pass. Answer yes, no or not determined(Y,N,ND) in the for the following statements. If"not determined"please 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 enfiltration or tank failure is imminent. System Hill pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank«ill 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 obstruction is removed distribution box is leveled or replaced NT) explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system «ill pass inspection if(«ith approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: Page 3ofll OFFICIAL INSPECTION FORNI - NOT FOR VOLUNTARY ASSESSMENTS Y SUBSURFACE SEWAGE DISPOSAL SYSTENI INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: J O h e Date of Inspection: a p C.,�Fuurther 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. I. System will pass unless Board of Health determines in accordance with 310 Ci♦1R 15.303(1)(b) that the system is not functioninb 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 vyetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier,if any determines that system i O .) t the y s functioning to a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system.has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance **This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: Page 4 of I I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEivi INSPECTION FORM PART A CERTIFICATION (continued) Property Address.- Owner: P �n P� 4 4 Od-6 6- p�J Date of Inspection: p D. System Failure Criteria applicable to all systems: You must indicate"yes" or"no" to each of the following for all inspections: Yes No/ l ackup of sewage into facility or system component due to overloaded or clogged SAS or ces of Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded logged SAS or cesspool d or _ — Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or I cesspool RigWd depth in cesspool is less than 6"below invert or available volume is less than '/;day flow equired pumping more than 4 times in the last year NOT due to clogged or obstructed i s . N of times pumped p Pe( ) umber 4�Any Any portion of the SAS,cesspool or privy is below high ground water elevation. portion of cesspool or privy is within 100 feet of a surface%titer supply or tributary to a surface water supply. XZ�portion of a cesspool or privy is within a Zone 1 of a public well. 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, Fcrformc•' DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates t::.:. me well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria arc triggered.A copy of the analysis must be attached to this form.] (Yes/No) The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. La be Systems: To be considered a large s%.stem the system must serve a facility with a design flow of 10,000 gpd to 15,0w) 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 fort 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 Ix,"Ze 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. Pagc5ofII OFFICLkL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORNI PART B �J CHECKLIST PropertyAddress:__l Owner: ✓ ©P2 Date of Inspection: /p p Check if the following have been done. You must indicate`dyes" or"no"as to each of the following: Yesi No Pumping information was provided by the owner, occupant, or Board of Health / V 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 v — Were as buiit 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 ins of the ' es or tees, material of construction, dimensions,depth of liquid, petted for the condition p quid,depth of sludge and depth of scum _ Was the facility owner(and occupants if different from owner) provided Rich information on the proper maintenance of subsurface sewage disposal systems The size and location of the Soil Absorption System (SAS) on the site has been determined based on: Yes no '- 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 approximadon of dis=cc is unacceptable) (310 CNIR 15.302(3)(b)J r Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORINIATION Property Address: .4n Cz4- Q Owner: Date of Inspection: S/a 2 RESIDENTIAL FLOW CONDITIONS Number of bedrooms(design): Number of bedrooms (actual): DESIGN flow based on 310 CNtR 15.203 (for example: 110 gpd x'of bedrooms): / /O _�7�' Number of current residents: S Does residence have a garbage grinder(yes or no):/VO Is laundry on a separate sewage system Lves or no):,V'o (if yes separate inspection required] Laundry system inspected(yes or no): /VO Seasonal use: (yes or no): A'O Water meter readings, if available(last 2 years usage(gpd)): Sump Pump(yes or no):ti o Last date of occupancy: l/eA, COKMERCIAL/INDUSTRUL 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 readings,if available:. Last date of oc::lipancy/use: O'T;.ER :, be): GENERAL L`rFORINUTION Pumping Records Source of information: 1_2L4 --If-;2G 'J_ Was system pumped as part of the inspection(yes or no):-v If yes,volume pumped:__gallons—How was quantity pumped determined'? Reason for pumping: TYP F SYSTEM eptic tank,distribution box, soil absorption system _Single cesspool Overflow cesspool _Privy —Shared system(yes or no) (if yes, attach previous inspection records, if any) _Innovative/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): Approximate age of all components, date installed Vf known)and sours of i ormadon: V — O Were sewage odors detected when arriving at*he site(yes or no):�� f Page 7 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: PTO -c— Date of Inspection: /a BUILDIING SEWER(locate on site plan) Depth below grade: iviaterials of construction:_cast iron /i40 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage, etc.): SEPTIC TANK:_l/(iocate on site plan) ) Depth below grade.- Material of construction: I/concrete_metal_fiberglass_polyethylene _other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):—(attach a copy of certificate) Dimensions: 4�5'x!aL Sludge depth: 6(/0 SG U ✓`l Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: c'� �j/p S lam, d e— Distance from top of scum to top of outlet tee or baffle: t7 Distance from bottom of scum to bottom 91 outlet tee q�baffle. How were d O�e Kimensions determined: 1' aS 4e— C Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet ' Vert, dense of leakage, etc.): / GREASE TRAP/V (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 li d levels as related to outlet invert,evidence of leakage,etc.): Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTENI INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: Date of Inspection: o ,p 11 tan TIGHT or HOLDI�ilG TANK: k 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/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.): DISTRIBI i vY Qr•C: v (present must be o n pe ed)(locate on site plan) Depth of liquid level abo%: Comments(note if box is Ic-.cl ar;d distribution to outlets le be into or out of box,et .): ems.any evidence of solids carryover,any evidence of f / -/(C s. !(/o PUMP CHAINMER: /y(kocate 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.): r Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORIM PART C SYSTEM INFORN ATION(continued) Property Address: 65� W- - 6� Owner: Tche Date of Inspection:� a O, SOIL ABSORPTION SYSTEM (SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number:_ leaching chambers, number: leaching galleries,number: caching trenches, number,length: leaching fields,number,dimensions: .So2��C �Zp 'X overflow cesspool, number: innovative/altemative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ndina etc.): 1/ / po soil,condition of vegetation. 7 rD✓�C A.��_ .�o j l (. �PG 6l Gr c.,cJ �r _ 11119 CESSPOOLS: c ' '� �esspovl must be pumped as part of inspec A)Oocate on site plan) Number and configuration: _ -. Depth—top of liquid to inlet invert: L)eptn 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 ponding,condition of vegetation,etc.): I ' • , OFFICIAL NSPECTION FORttit— NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM IINSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: .rm"d S Date of Inspection: p p SKETCH OF SEWAGE DISPOSAL SYSTEIN1 Provide a sketch of the sewage disposal system including tics to at least two permanent referent,- landmarks or benchmarks. Locate all veils within 100 feet. Locate Where public water supply enters the building. Fro h ,4S_ t 6/ - 0 I , 1 V i \ No le �y- 31 �Q�� rein Pagc 1 I of I I I ^ OFFICIAL INSPECTION FORM— NOT FOR VOLUNTARY ASSESSNtENTS •r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 051 9f 6 Owner. ern v l �70, Date of Inspection SITE EXAM Slope Surface water Check cellar Shallow wells i Estimated depth to ground water feet `� 0/ /G`� 0`x P-t Af 1701t)L Please indicate(check) all methods used to determine the high ground water elevation.- Obtained from System design plans on record-If checked date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Hcalth—explain: Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must desc 'be w you established the//high ground water elevation: / A Oc/y OT f�6af1 �i�IC I !�/l✓ �'C, 1 Q �otiH wd f TOWN OF BAR LOCATION MAIMSEWAGE # VII,LAGE�, ASSESSOR'S`ML AP & LOT INSTALLER'S NAME&PHONE NO. &A Q�''''�� S '�" Td`%Y SEPTIC-TANK CAPACITY LEACHING FACII..T'TY: (type)./ (size)Y1'-X Z0 NO.OF BEDROOMS ^^ BUILDER OR OWNER .4 r So PERMITDATE: ate, CPMPLIANCE DATE: qi On gar � I Separation Distance Between theft Maximum Adjusted Groundwater"1 able and Bottom- of Leaching Facility LKSl G Feet Private Water Supply Well and Leaching Facility (If any wells exist J on site or'within 200 feet of leaching facility) 15y Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leachinkf�lity) 1 Feet Furnished by _ -- .. ... .... ,. _...- . 0 N F 03/12/2006 16:17 16172229749 FUREY PAGE 01 r oFiiq'„ CERTIFICATE OF ANALYSIS cti �►�• Page: 1 of 1 Barnstable County Health Laboratory (MTMA009) t��nr ruy ft2 ji ' Prepared For: Report Datod: 7/8/2014 Sheili3 ;3ournival Bursli: Manor Order No.: G1481138 651 h.4 On St. West 1;arnstable, MA 02668 Laborato In*, °i+4,81'138-01 Description: Water-Orinking Water Sample#; i� Sample Location: 651 Main St„W.Barnstable Collectad: 07101I'2014 Collected by: ustomer Received: 07k1 2014 . Routine ITEM RESULT UNITS RL MCL METHOD## TESTED Nitrate as Nitrogen, ND mg1L 0.10 10 EPA 300.0 7WO14 Copper 0.035 mg1L 0,0030 1.3 EPA 200.8 7/3014 Iron ND mg1L 0.10 0,3 EPA 200.8 7/3/2014 PH 7.1 PH AT 25C NA 8,5-8.5 SM 4500-11-13 7/1/2014 Sodium 35 mg1l. 1.0 20 EPA 200.8 7/=014 Total Coliform Absent P/A 0 0 5M 9223 7/112014 Conductance 160 umohs/cm 2.0 EPA 120.1 7/1=14 Sodium level is at we the maxitim contaminant level, Those on a low sodium diet may wish to consult a physician, ; 4'd 8 ; ' .4#tache;f �le2ss Find the laboratory certified parameter list. Approve Y •�^C�� ;Lab Director) — -• ._.. _ . _. . _ _ I.I. --- - - - ---— �//��b q '1 I IN 1) NoT Detected RL = Reporting Llmit MCL-Maximum Conteminant Level Su:tenor Court House, PO. Sax 427, Barnstable, MA 02630 Ph, 508-3764605. r 03/12/2006 16:17 16172228749 FUREY PAGE 02 t ` 1 GQMMUNWEALTH OF MASSACHUSETTS DEPARTMENT OF ENVIRONMENTAL PROTECTION . Certified Parameter List as of;01 Jul 2014 M-MA009 - 1ARNSTABLE COUNTY HEATH&ENV DEPT,BARNSTABLE,MA na s Method for NON-Pp ble Water 3Rethods fo Potablo Water ALUMINUM EPA 200.8 ANTIMONY EPA 200.8 EPA 200.8 ARSENIC EPA 200.8 EPA 200,8 BARIUM EPA 200.8 BERYLLIUM EPA 200,8 EPA 2018 CADMIUM EPA 200.8 EPA 200.8 CHROMIUNI EPA 200.8 EPA 200.8 COBALT EPA 200,E COPPER EPA 200.8;SM 31118 EPA 200.8;SM 3111 B IRON SM 311113 . LEAD EPA 200,8 EPA 200.E MANGANEEil EPA 200.8;SM 3111 B MERCURY•I!I EPA 200.8 -.-.- -NICKEL. .. : . EPA 200.8;SM 3111 B., ._-EPA 2.00.8;SM 31 V B• SELENIUM I EPA 200.8 EPA 200.8 SILVER . EPA 200.8 EPA 2.00.8 THALLIUM EPA 200.8 EPA 200.8 VANADIUM EPA 200.8 ZINC EPA 200.8;SM 3111 B PH SM 4500-H-8 SM 4500-H-6 SPECIFIC Cc IDUCTIVrTY EPA 120.1;SM 2510B HARDNESS( ;AC03),TOTAL SM 23408 CALCIUM SM 3111E SM 3111E MAGNESIUM SM 3111E SODIUM SM 31 11 B SM 3111 S POTASSIUM SM 3111 S ALKANILITY SAL, SM 232.0B SM 2320B CHLORIDE EPA 300,0 FLUORIDE- EPA 300.0 SULFATE EPA 300.0 EPA 300.0 NITRATE-N EPA 300.0 EPA 300.0 NITRITE-N EPA 300.0 TURBIDITY EPA 180.1 TOTAL DISSI.VED'SOLIDS SM 2540C $M 2540C NON-FILTE 'I'LE RESIDUE(I'SS) SM 2$40D TOTAL OFRO i dC CARBON SM 5310B CHEMICAL "GEN DEMAND HACH METHOD 8000 BIOCHEMICh OXYGEN DEMAND SM 5210B TRIHALOME711'4NES EPA 524.2 VOLATILE HAi OCARBONS EPA 624 VOLATILE AFw 1MATICS EPA 624 VOLATILE OR IANIC COMPOUNDS EPA 524.2 1,2-DIBROMt;V FHANE EPA 504A 1,2-DIBROM(:L I-CHLOROPROPANE EPA 504.1 PERCHLORA'i EPA 314.0 HETEROTRC F IIC PLATE COUNT SM 9215E TOTAL COLIF( ;RM MF-SM 9222B TOTAL COLIF( IRM EPA 1504 TOTAL COUP( ISM ENZ.SLIB.SM 9223 FECAL COLIF'( 14M MF-SM 9222D MF--SM 9222D E.COLI EPA I503 EPA 1504 E.COLI EPA 1103.1 NA-MUG-SM9222G E.COLI MF-SM 9213D ENZ.SUB.SM 9223 ENTEROCOO. EPA 1600 EPA 1600 Effective Date:01 July 2014^Explmtlon Date:30 Jun 201 pF f9q�y, CERTIFICATE OF. ANALYSIS M Barnstable County Health Laboratory (M-MA009) �9sr1rtn±��^� Recipient: Sheila Bournival Matrix: Water-Drinking Water Bursley Manor Sampled: 11/03/2015 11:15 651 Main St. Received: 11/03/2015 11:38 West Barnstable, MA 02668 Collection Address: 651 Main St.,West Barnstable Order#: G1590980 Sample Location: Description: R E Kit Lab ID: 1590980-01 Date Analyzed: 11/3/2015 @ 13:33 Sample#: Analyst: yn Method: EPA 524.2 Dilution Factor: 1 Comment: Sodium level is above the maxium contaminant level.Those on a low sodium diet may wish to consult a physician. PH is high (6.5-8.5),and retesting is recommended. EPA 524.2 - Volatile Organics by GC/MS Result MCL MDL Result MCL MDL Parameter ug/L ug/L ug/L Parameter ug/L ug/L ug/L Dichlorodifluoromethane ND 0.50 Chloroform ND 80 0.50 Chloromethane ND 0.50 cis-1,2-Dichloroethene ND 70 0.50 Vinyl chloride ND 2.0 0.50 cis-1,3-Dichloropropene ND 0.50 Bromomethane ND 0.50 Dibromochloromethane ND 0.50 1,1,1,2-Tetrachloroethane ND 0.50 Dibromomethane ND 0.50 1,1,1-Trichloroethane ND 200 0.50 Ethylbenzene ND 700 0.50 1,1,2,2-Tetrachloroethane ND 0.50 Hexachlorobutadiene ND 0.50 1,1,2-Trichloroethane ND 5.0 0.50 Isopropyl benzene ND 0.50 1,1-Dichloroethane ND 0.50 Methylene chloride ND 5.0 .0.50 1,1-Dichloroethene ND 7.0 0.50 Methyl-tert-butyl ether ND 0.50 1,1-Dichloropropene- ND 0.50 Naphthalene ND 0.50 1,2,3-Trichlorobenzene ND 0.50 n-Butylbenzene ND 0.50 1,2,3-Trichloropropane ND 0.50 n-Propylbenzene ND 0.50 1,2,4-Trichlorobenzene ND 70 0.50 p-Isopropyltoluene ND 0.50 1,2,4-Trimethylbenzene ND 0.50 sec-Butylbenzene ND 0.50 1,2-Dibromo-3-chloropropane ND 0.50 Styrene ND 100 0.50 1,2-Dibromoethane(EDB) ND 0.50 tert-Butyl benzene ND 0.50 1,2-Dichlorobenzene ND 600 0.50 Tetrachloroethene ND 5.0 0.50 1,2-Dichloroethane ND 5.0 0.50 Toluene ND 1000 0.50 1,2-Dichloropropane ND 0.50 Total xylenes ND 10000 0.50 1,3,5-Trimethylbenzene ND 0.50 trans-1,2-Dichloroethene ND 100 0.50 1,3-Dichlorobenzene ND 0.50 trans-1,3-Dichloropropene ND 0.50 1,3-Dichloropropane ND 0.50 Trichloroethene ND 5.0 0.50 1,4-Dichlorobenzene ND 5.0 0.50 Trichlorofluoromethane ND 0.50 2,2-Dichloropropane ND 0.50 Surrogates %Recovered QC Limits(%) 2-Chlorotoluene ND 0.50 p-Bromofluorobenzene ' 70% 70 130 4-Chlorotoluene ND 0.50 1,2-Dichlorobenzene-d4 80% 70 130 Benzene ND 5.0 0.50 Bromobenzene ND 0.50 Bromochloromethane ND 0.50 Bromodichloromethane ND 0.50 Bromoform ND 0.50 Carbon tetrachloride ND 5.0 0.50 Chlorobenzene ND 100 0.50 Chloroethane ND 0.50 Attached please find the laboratory certified parameter list. Approved By, (Lab Director) ND=None Detected RL = Reporting Limit MCL=Maximum Contaminant Level 3195 Main Street, PO. Box 427, Barnstable, MA 02630 Ph: 508-376-6605 Page 1 of I °� "R '� CERTIFICATE OF ANALYSIS Page: 1 of 1 L Barnstable County Health Laboratory (M-MA009) Report Prepared For: Report Dated: 11/4/2015 Sheila Bournival Bursley Manor Order No.: G1590980 651 Main St. T West Barnstable, MA 02668 �- w, Laboratory ID#: 1590980-01 Description: Water-Drinking Water C J! 'Sample#: Sample Location: 651 Main St.,West Barnstable Collected: 11/03/2015 -; Collected by: Customer Received: 116/2015 Routine ITEM RESULT UNITS RL MCL METHOD# ANALYST TESTED NOTE Nitrate as Nitrogen 0.60 mg/L 0.10 10 EPA 300.0 LAP 11/3/2015 Copper ND mg/L 0.10 1.3 SM 3111E LAP 1 1/412 0 1 5 Iron 0.17 mg/L 0.10 0.3 SM 3111 B LAP 11/4/2015 pH 9.6 PH AT 25C NA 6.5-8.5 SM 4500-H-B DCB 11/3/2015 Sodium 170 mg/L 2.5 20 SM 3111E LAP 11/4/2015 Total Coliform Absent P/A 0 0 SM 9223 RG 11/3/2015 Conductance 770 umohs/cm 2.0 EPA 120.1 DCB 11/3/2015 Sodium level is above the maxium contaminant level. Those on a low sodium.diet may wish to consult a physician. PH is C high(6.5-8.5), and retesting is recommended. Attached please find the laboratory certified parameter list. Approved By: (Lab*Director) 011 ND=None Detected RL = Reporting Limit MCL=Maximum Contaminant Level 3195 Main Street, PO. Box 427, Barnstable, MA 02630 Ph: 508-375-6605' f��C1E tin�Nj'`' CERTIFICATE OF ANALYSIS Page. 1 Barnstable County Health Laboratory Report Dated: 11/10/2005 Report Prepared For: Sheila Bournival Order No.: G0533665 Bursley Manor 651 Main Street W. Barnstable, MA 02668 Laboratory ID#: 0533665-01 Description: Water-Drinking Water Sample#: 33665 Sampling Location 651 Main St.W.Barnstable,_MA Collected: 11/9/2005 Collected by: S.Bournival Map 156 Parcel 057. Received: 11/9/2005 Routine ITEM RESULT UNITS RL MCL Method# Tested LAB: Inorganics Nitrate as Nitrogen BRL mg/L 0.10 10 EPA 300.0 11/9/2005 LAB: Metals Copper 0.38 mg/L 0.10 1.3 SM 3111B 11/10/2005 Iron BR-L mg/L 0.10 0.3 SM 31 1 1 B 11/10/2005 Sodium 76 mg/L 1.0 20 SM 3111B 11/10/2005 LAB: Microbiology Total Coliform Absent P/A 0 0 309 11/9/2005 LAB: Physical Chemistry Conductance 370 umohs/cm 1.0 EPA 120.1 11/9/2005 pH 7.2 pH-units 0 EPA 150.1 11/9/2005 (Sodium level is above the maxtmum2ontaminant'level=Those on a low sodium diet may wish to-consult-a'f. p stcian h Approved By ((LA Director) _ C r. • � N A .. •-... ,tap; -_ rn RL = Reporting Limit MCL=Maximum Contaminant Level Superior Court House, PO.Box 427, Barnstable, MA 02630 Ph: 508-375-6605 IL • of t o� TOWN OF BARNSTABLE IME Date !.� LICENSE APPLCGATION .` New APPhcatton sa>itrrsrnet E ne . ewa g 200 Main Street zd39. fer 10rEn r °. Hyannis,'MA 02601 508-862-4674 Other --► . NO BUSIN M ESS AY OPERATEWITHOUT A V LICENSE IC'ON T PRNII ESES ,4-- • Name of applicanYcorporation _.• «.. _ .,Home phone Address of applieant/corporatton f - 10 C � j $. Business phone 1: D/B/A ' !-�a .,C1 _ — Business phone#` ems y Business location: kg ,/&44S 461 Business mailing address: Local 6usiness�address: 7. Local mailing address — �' -_ ..;� � _. w_ — LICENSE TYPE -. � ! ..... /"�Q+.t.�'E' Annual Seasonal HOURS OF.OPERATION: s. �►�—. " .`!�!� ,Fib Em43 Name of manager ' s�r"`� #`�f,�y _ �— ---- • :!) j .. Local mailing.address: . ,. ( Lt ✓�� .: g ' Manage['s Permanent mailing address 02 Manager's home phone#,' �_j&Pak If If `' Bislness phone#: l .~ Name of property owner: —. -- - ASSESSOR'S MAP/PARCEL# IAP � PARCELJ= ....... t rList.any.flammable substance or hazartlous waste used in.bustness(specify) Applicants mu' t contact the Building ,Commssaoier�;s office, (508) 862-4038; the "Board: of. Heal"th office, (508) 862=4644, and the' appropriate:,Fire District office to schedule inspection. b Signature of applicant .. ... °Fo �+n.useonly REAL ESTATE TAXES PAID:IN,FULL AGREEMENT IN EFFECT ON PAYMENT IS THIS USE PERMITTED WITHIN THIS ZONING DISTRICT? YES NO O INSPECTORS APPROVAL ... _•__._.�_.. Capacity set by Building Dt�tsion•..� _ __ _ Building/Zornng ._ ____ ___._._ — Date _... _ _ Board of Health _ __.__ — Date -- . Wire --=-- Date. __�� Plumbin --- 9 --- _ - — -—Date. Gas -=----_ —..... Date Fire District Date _ ...........-- . ----------- Comments:—_-— --- --- ---White.Licensing Authority Canary=Heafth DMsion Gold.-Building Commissioner Pink•Fire Department TOWN OF BARNSTABLE BOARD OF HEALTH ARTICLE 11:MINIMUM STANDARDS FOR HUMAN HABITATION Date u h g1®3 Owner Tenant c� Y Address Address (A >? �lJ• � / �� Com liance Remarks or Regulation# Yes IYNo Recommendations 2. Kitchen Facilities �- 3. Bathroom Facilities 4. Water Supply 5. Hot Water Facilities 6. Heating Facilities � Q --- 7. Lighting and Electrical Facilities 8. Ventilation �-- v 9. Installation and Maintenance of Facilities v 10. Curtailment of Service 1/ 11. Space and Use 12. Exits 13. Installation and Maintenance of Structural Elements 14. Insects and Rodents 15. Garbage and Rubbish Storage and Disposal 16. Sewage Disposal 17. Temporary Housing PART II 37. Placarding of Condemned Dwelling; Removal of Occupants; Demolition Person(s)Interview Inspec o If Public Building such as Store or iQ/Motel specify here No. �� " Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS &opooAY 46potem C onotruction Permit Permission is hereby granted to Construct( Repair GA-)Upgrade( )Abandon( ) System located at 5-1 /Z 7-&A 175541,1- 4'? and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of Date: �! ��t` Approved by��2/L���`--`— G/ s.. I V .fie- _ -' }" Fizs N ......%�t�r.''..... �. .... THE COMMONWEALTH OF MASSACHUSETTS �4 r BOARD OF HEALTH .: ��Wn....................oF......1�4!'.!1s.... .m......------...............--••----....--.---......... y.: l �xttfioit for Diopootti Works Tottotrur#toit Wrmtf Application is hereby made for a Permit to Construct ( ) or Repair (44Q an Individual Sewage Disposal System a� --••...... . ..... ......................•----..............--•-••-----•---•----.....-•----...------.......-•----.... STRAerISSLoca t'rn Address .................... ,g Lot D:Q• 0------------•-- --------- ... ---•---•--- ---M. R Installer O,�ner r n AddressAd ress (� w .......................... . . .............................. ► Type of Building Size Lot............................Sq. feet U Dwelling No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ...... No. of persons............................ Showers ( ) — Cafeteria ( ) aOther fixtures ...--------•------------•--....----•--••------•--......-------------------•-------------------------•----...-•---...-•-------•--..................... W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. 1y4 Septic Tank—Liquid capacity------------gallons Length................ Width................ Diameter--.............. Depth................ Disposal Trench—No- -------------------- Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter..._................ Depth below inlet_____._.._._.....___ Total leaching area..................sq. ft. z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit...._............... Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Pa' •-••-•-•--•--•---•••••---•••-•••..........................••-••.••-••.............. ..-•------------ --- .--------------------------- --------------- •---------- ODescription of Soil........................................................................................................................................................................ x W .Poe) _a/1 -•--------•---------'-------•--••••--------•----••-••----•-•-----••-••-----•-•--•-••••----•--.........•--/......---- - .....•. ---.-- U Na re of Repairs or Alteratio s—Answer when p,plivable.-4 n.4._ ._���_Q. Oyu-..-. -_. t. PI..: �-•--__. V �!41�+ I�451-4,►.16 ..tz n .0 ..-hAc us1S�,�1 ... i`-a ._.. ....---•-•................. 1 .�: � ... �U Agreement: u The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of T IT LZ 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has bee uue by the board of 1 ealth. igned•-- .t...Ku... ...... -- •-----........... ---- 8 8 V rDj`te Approved B _ 1 Application PP Y----------------------- •-•-- •---- -•-----..... _ .. ..---..............----•- ----•- -----'Da: - Application Disapproved for the following yeas ns...............................................................................................................- ................................•------•----••------............_....---•--•----.............------•-•--•....._...--------•----------••---•-••--.................................•• Date......._---- PermitNo......................................•--•---•-------•.- Issued......................................................- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEAL,.T _. 1• n..............OF........... .. '..r ...^�...�e.................................... Trrtif irtt#r of fIoutIltittnrr TI iS IS TO RTIFY, That the Inulxld 1 �w �isposaLSystern constructed 'or Repaired OL) V-�=•�-------•----•---L=L'-... ................ ......;C ) ........ Installer at.. Q�e 9- has been instailed in accordance with the provisions of TI T IE 5 of The State Sanitary Code as described in the � application for Disposal Works Construction Permit No....�.....�30_.� dated......� � S`.....---------------- THE ISSUANCE OF THIS CERTIFICATE SHALL NUT BE CONSTRUED AS A GUARANTEE THAT YHE S t Sl EM VIIJI.L, fUNCTION SATISFACTORY. . y . .. � ......................•--•--........---.._...-•--- DATI:................li �.........................---................ Inspector s, �I/ Joseph D. DaLgz Telephone: 775-1120 Building c:'ammismioner Ext . 107 TOWN OF BARNSTABLE BUILDING DEPARTMENT TOWN OFFICE BUILDING HYANNIS, MASS. ' 02601 April 23 , 1990 Ms Marilyn E. Strauss 651 Route 6A West. Barnstable, MA 02668 Re: Site. PIan Review Number 18-90 Corner 6A and Maple St . , W. Barnstable Dear Ms Strauss: The Site Plan Review staff has approved five (5) parkin spaces - g p for the parking area shown on your plan. However, a Variance must be granted by the Zoning Board of Appeals to allow more than three (3) lodgers. Should the Board of Appeals grant a Variance, you must comply with the requirements of the Board of Health. A Lbdging House license is also required. Information regarding this license is avai.Iable in the office of the Town Manager. Should you have any questions, please feel free to call . Very truly yours, Jo h E. Bartell Si' e Plan .Review JEB/km cc: Town Manager ZOI)i ny Board of Appeals All Sits? Plan Review staff f it • SITE PLAN `APPROV'Ai, DOES NOT OVERRIDE REQUIRED PERMITS \ SITE Pl-AhJ hEV I_ EW FOR OFFICE USE ONLY p ' APF='L I CAT I ON .. � IIAIINSI'.MILE, DATE RECEIVED ,. 111.\Ss. a ACTION DUE BY �/ 6 r •..__ ��` S I TE PLAID 11 SP -/ p ACTION DATE OF ACTION LOCATION Legal Description :'H 156 - 057 Deed Ref: 14.76/01.2 0/00 Planning Board Subdivision Number: N I� -" Assessors Hap and Parcel,-Number: 1 1 �6 Parc el property Address: o s OWNER = Name! APPI_I CANT W 1' a•r i � ,rn N ra„S s Name: Owner ,� MAR I'j a�1 I'm Address �[� a+� — -•.•. _-,• - Address W Barnstab e, Phone: . Phone: DEVELOPER 9 Name: N/A CONTRACTOR Address: Name: T/ Address: Phone: _ - Phonc: _ ENGINEER Name: AGENT Name: N/A ' Address: __. Adclres;; Phone: - •----_______�. ZONING CLASSIFICATIONS District: STORAGE_fn_rrl_t(S) UTILITIES Flood Hazard: EXISTING: PROPOSED: Number: 1 Sewer.: g�.> Groundwater Overlay: Number�e Publ 'Size:- 2_- 5��ral Size: PrivaL .LOT AREA: 1 acre Above Ground: g Above Ground:_ Wa'ler: -----__ SQ.FT. Underground:,-- Underground: Public:. - NUMBER OF BUILDINGS Contents ng Contents: Private_ : 2 Proposed: PARK NG SPACES CURB CUTS Electrical : Proposeedd: �- Aer is i : X. Demolftlon:� Provided: + Existing. 2 Underground: — On Site: Proposed: Gas: TOTAL FLOOR AREA ( In sq. Ft. ) OfF s; le; '� Close r Natural : no Res.i dent i a l : 60 c <c7 I Propane: no .- ---- Office: Other: Medical OF --' IfJ tll�'I'ClRlr.nt. ICI: II;Ir'f:_. Commercial : tlu�nc: Wholesale: BUILDINGS OVER 50 YRS. OLD: 2 � Aerial :�_ Institutional : (t1)--- Underground: Industrial : - - IN ARf:A (?I (:I,I1Ir;n(. h:NVII;UIJhIi:NI'AI_ r'�I'Ic. TV: CONCERN - ----...__._....... Underground: Plot. Plan :showing:. Location as' to..5treets •Perimeter lot measurements.. -Location of .•-buildings " Dr1vewa'y. and parking existing ' Yard lighting'.ex`i.sting Yard l.iqWn tic d 0 E GCSrl y rn . OW . d p 23691 • zo � � �' N• •• i NyIr'S G•�ehr.. 4' Y •o f..l • • .CorL'8 •, . • I .2 :rM S� !; PLAN OF LAND IN WLtjT DARNSTABLE_ MAC, a Included in this packet : A . Informational ,pages .cut together for prospective buyers 1. ) description of the hotasc 2) historic importance 3) layout of rooms and, their electrical outlets 4) of nt la;Tout, 5) neTaspapei article I.:i..:;i;::I.nn it on ,lation.al F;egister B. Diagram of the ground floor. of the house C. Diagram of the second floor of the house D. Diagram of the main attic L. Letter sent to my neighbors U 12 MAR r1[3 j990. w � 5 9 _• I Salt & Chestnut "Weathervane Shop"' American handcrafted vanes West Barnstable IVA „hc M 1 .IWt_ 1i(4J j' rN 1 A 15, •y� ' � Y y, fat .q .. ••#,.. - - I •' 'r�.,'�...,a' �� 1H' ��3t-�s..�'14r�".�:'.1.�..Vr .r4...:�,. s. .� . s.i�y .r�l�.; ' First time offered in over k3 years, this property has received national publicity . including Newsweek, CBS, National TV News, UPI, and numerous trade and travel magazines,g es. This"Bursley Hornestemr,runs home hr Dine yenerations of their family and it is the house where 'Mad' Jack Percival rehu-necl frequently to visit his childhood friend and it was he who brought the special trees for this property. This is a very historic home and site. It has-been well preserved and would lend itself to a Bed& Breakfast operation. The setting is superb with lovely countryside views. Real estate and business offered together...Call today for details...Exclusive. HISTORIC NINE WINDOW , CENTRAL CHIMNEY. COLONIAL WITH TWO EXTENSIONS , ON'ROUTE 6A (OLD KING 'S HIGHWAY) AT THE CORNER OF MAPLE STREET IN WEST BARNSTABLE, MASSACHUSETTS . This 1+ acre property is within a` National Register of Historic Places preservation area and is one of the very important sites also designated individually. LOT is a generous acre above the flood plain surrounded by open land. The primary view. 1s across 6A, a pond a.nd open; groomed land beyond .which can be seen the tops of Sandy Neck dunes from the ground level, marsh and dunes from the second floor,, and Cape Cod i ' Bay from the attic. A third of the acre is woods andsthe cleared portion has a brick walked , stone walled picnic area surrounded. by, a half circle blacktop driveway with both ends opening to Maple St. Huge chestnut trees , an elm and a sycamore border the .frontage . and within the property are several huge maples , apple, pear and peach trees , plus concord grapes , raspberries , currants , rhubarb and asparagus . THE CENTRAL PORTION OF THE HOUSE has 12 rooms plus 1ff'- baths and 9 closets. The rooms are based on a 142 ft. square rather than the usual 12 ft. and the ceilings are also a generous 7ft. gin. There are .4 working fireplaces plus the large common room fireplace with beehive oven that I have not had time to open. A 7th entry .. to the chimney on the second floor is of stove pipe size. . The main stairway (1 of 3 in the house) is the typical center front with ballustrade hall on the second floor. This 'area .retains some of its Victorian wood-grained decoration. Beneath this stair- way is the access door to the open area below the vaulted chimney from the fireplaces . On the main floor one front room has 1j walls of bookshelves while the other has the ceiling removed to show the . handcut beams , peg , construction and wide boards above. The dining room ,and, common room have hardwood floors and the remainder of the house has wide pine boards , some with old spatter paint: Most of the first floor' woodwork has been stripped to natural. Two 12/12 windows remain:` : In its ATTIC are 2 additional rooms partitioned with t/g wood" paneling; one with a closet. Steps to the top of one of these _ rooms lead to a platform and the roof access . (This was originally for. fighting chimney fires rather than for a view of Cape Cod Bay , . and has been temporarily roofed over. ) THE NVJ EXTENSION completes the main part of the house and con- tains the kitchen and pantry with stairs to a cellar and work room. The stairway to the second floor has a separate front entrance that can be closed from the central portion of the house. Above the kitchen is a spacious room with 5 windows and 2 huge closets- -a wonderful secluded studio. AN ELL TO THE SW contains a summer kitchen with a closet and corner cupboard, a wash room with fire pit to boil laundry, and an attached carriage shed.. A separate stairway gives access to 2 un- finished rooms above. A SEPARATE CARRIAGE SHED completes the structures. ' It has not been maintained but is not beyond restoration. Beneath it is a cellar in which previous owners had their own power generator. (2) i I DO Ea r� 4t HEAT is by oil from a 500 gal. underg-round tank. The steam radiators are nicely placed and are not objectionable in view but could be .easily concealed. A fuel-efficient burner has been •1n- stalled in the furnace recently. There is .modern. insulation and, storm windows. throughout the main house. The house has been - a humidified in winter. he< as j Ibo H^vi=. CONQ3L.c=, bt'�41 ihS�a . West Barnstable does not yet have access to town WATER, SEWER or - but this property has excellent TV..reception,` ' abundant water and a newly up-graded septic system. The ELECTRICAL wiring has all been replaced and there are more than adequate outlets including 220 lines . A circuit breaker box was installed last year at the ground floor level. There are 7 outlets for one TELEPHONE line plus one Jack for a second independant line. There are ALARM SERVICES for heat , smoke and motion tied to . . a full time agency and police. The house was checked . for INSECTS & PESTS .18 years ago, and` has been on regularly scheduled service since that time, The house was painted recently and at that time the structure was checked and found to be SOUND. At each end of the driveway is a post lamp topped with 17C London street lamp, thus providing YARD LIGHTING. The wiring is buried but access is provided at the steps to the picnic area. This property was the first to be settled in',W . Barnstable �`(1640) The heart of the present house was built in 1670 when :the original house burned. Major additions were done in 1740 and` again in 1840. This Bursley Homestead was home to nine generations of their family and has been in the possession of the present .owner since' 1969. It is the house where 'Mad' Jack Percival returned frequently to visit his childhood friend and it was he. .who brought. the special trees for this property. (Jack Percival was the naval captain who salvaged Old Ironsides (USS Constitution) and sailed it around the world in the 1840s . This ship now sits in harbor at Boston. ) This is a wonderful house, very private and with a variety of beautiful views in every direction. Part of the house is used as a unique and pros ..pering business . Loning. is for 'family business ' which allows for one employee other than the immediate family. The business has grown to the point of being 16 hours .a day forme and growing steadily. There is no family member with whom to share responsibility and rather than hire a partner, I will sell. The house and business do not have to be purchased together but `it would be a great opportunity. Q vrr CLI11 S•hC)ttlfhJ ��{,LC Lk,C..C?'lU2, Q� .......... cn Iq I i rnrn .-....._............... L- IeJc'tco-� 0uf ets. CX IC&Li0( aF t11�.. hccise cLLSO 560u;s yoLk,JAje. (-kc�F.'uc;c _..........-. .. -- _. _ _........... _.. - e — Vb • z ��. Plot. Plari :showing:. Location as' to. :Streets I' •Perimeter lot. measurements., •Locatlon of...'iuildings llri•veway. an d• parking existing Yard lighting':.existing �: Yard L���-�i�� • • ' •. : . . ' • .. ® se. • .PLC' •. • pr'• . . O 'IC3800c . z4 y .• . s •Y�11'�ylt'i5�. a ... .2 PLAN OF, L.Ar rp IN WCSTBAnNSTABLE. MARS CAPE COD TIMES; SATURDAY,'MARCH,28,1987 PAGE 3 R ; arY nstab i e s ®u . HISToriteve 6A laced in . B GREGOR �. • y. Y BRYANT 300 outbuildings (such as barns),five ceme- their historic significance to the district. STAFF WRITER teries, ancient Indian camp grounds, miles- In Barnstable Village the properties with- Jones, monuments; and remains.of long de- in the new district include the Crocker Tav-� iona eemir TABLh f Ro one sweeping move; cayed 'structures, said Ms. Anderson.- It , ern (circa 1754), the Old Colonial Courthouse the.entire length of Route 6A in Barnstable encompasses Route.6A from theYarmouth (1774)at Route 6A and Rendevous Lane and � I has been named into the National Register of line, through Barnstable Village and West the Sturgis Library, a portion'of which — Historic Places, creating one of the largest Barnstable to the Sandwich town line. built in.1644 as the home of the Rev. John 1 such historic districts in the country. Every property that abuts Old King's High- - Lothrop — is the oldest known remaining • The new district is called the Old King's way,the former name for Route 6A, as well building in Barnstable,she said: register � ' C��Highway National Register District,said Pa- as some behind these, is included in the new In West Barnstable are the Bursley Home- J tricia Anderson, inventory director for the district,she said. 7 stead (circa 1827), at 651 Main St,; And.the Barnstable Historical Commission. The district, ,however, distinguishes Howland Homestead (1882),at Packet Land-: And it all became official,when the pro- .between the old and newer houses along the ing Road and Route 6A. posed district was formally accepted recent- nine miles of highway through the town,.said Old King's Highway was one of 13 historic ly by the Keeper of the National Register in Ms. Anderson. Those buildings constructed districts throughout Barnstable—represent- the federal Department of the Interior, she before 1930 are called "contributing build-, ing about 1,000 properties — submitted for said. ings while those constructed after that are inclusion in the National Register by the The district Includes 500 main buildings, "non-contributing buildings in tern1s of Barnstable Historical Commission, Nomina- tions for 75 individual buildings were also their renovation,as well as state and national submitted. recognition that their property is worth Thus far,only the Old King's Highway dis- preserving. trict, the largest of those nominated in Barn- ' The Barnstable Historical Commission . stable, has been accepted. "But we don't worked for about 10 years to document every anticipate any problems with the remaining structure in town built before 1900 which met properties, said Ms.Anderson. guidelines of the National Register of Histor The National Register designation carries is Places.Last August, the scattered proper- no building restrictions and is not connected ties, submitted under the multiple resource to the Old King's Highway Regional Historic nomination process, got the unanimous sup- District.Regulations of the local historic dis- port of the state review committee,.which trict will remain in force. forwarded the nominees to Washington D.C. The district.will join the approximate for final review. 47,000 other listings on the National Register, Last month the properties were formally ; created by Congress 20 years ago to revita- nominated by the Department of the Interior' lize deteriorating downtowns in American through a notice published in the Federal cities.It offers tax incentives to save historic ;Register. The notice virtually assures 'ap- buildings from demolition and encourage 'proval of the properties as historic places. i I �I UJIA - Foyer B /"ooPat k in �+ BeW�oo Pos RoQm. shower `� 11ff 11 v '-ate,. 11410 W0. 10 4 Lz� peo k Close+ . a z CA set G'/o`lef Fei k��'3 j ewn 1L �nd Floor Prom Rfe (,A �i u rG(/✓7 Ca.r 0 0.nCe s'leot f. { 1 I • En4raa,ac � p WOCL cod rr, C•\ose} Summer Entrance - I� ' -� En�ranc e Cn�ro.nce io Cellar Up Aou;n t,,ajr�•�ntr'att(:.i — 54•ooP' B.Aropm Down �r'n mo n RpOfYI l/tntY � Room r Pangy k tchec> �eAroo m =tax Fireplace �wv,.• ".•r 4, i (_ibrarY P.L l0C ' nf ran oe ro Close UP;' Ground Floor ,::rA. M • Er&cLnce Fror, Rte boa , r l I s . Sfa�rs from �C�►�m ne.y ' boo m CLose-f rro�{ 01 (l�uSe 3 t� ebruary, '1990 .: f i Dear Neighbor, I am requesting that the `i'ot,an of 3,zD.rnstable allow me to use my house as a 3ed &: 3reakfast facility. ' . Since I have been unable to sell the property during. thelpast '.4 i I . i two years , I must do something . I cannot financially handle its upkeep; nor can I much longer live alone. Eric will soon be . , . leaving the area and I have no other immediate family. A Bed & Breakfast seems a wonderful solution as a means':;, to maintain this historic property as an. asset to the neighborhood'. However, I am not able to do this on my own. I have a nephew who could move here from California. He doesy- not . have the finances to purchase the property but he would- be' able financially to make the necessary renovations , run the B&B, keep up and improve the grounds , and provide to me some financial assistance. I hope I have been the good neighbor and custodian of this. marvelous homestead and, since I will continue to be the gwner, this will not change. It will 11 in fact be enhanced wit h Improved ` . ' p landscaping and care to become a greater asset to the community. The problem that will have to be overcome is the limited number of guests . There are five bedrooms on the aecgnd floor, and I "will be requesting eventually to use all of them for guests (My bedroom would necessarily remain on the ground floor. and my nephew anticipates developing; the t�-,o attic roorns for ,their private use when finances allow, . ) I .hope ,you will support my request ; hen the hearing is scheduled by the Town. Thank you e.y for ,your conslderat�-or. .:�.nd help. If you have any questions , please call me. Very truly yours , '',aril yn Strauss 362-301.2 _ -- --- No.----------- Feel---- OF HEALTH TOWN OF BARNSTABLE App[ccatcon,forVe1I Conotructionj3ermct . C)s Application is hereby made for a permit to Construct (-4'Alter ( ), or Repair %" individual Well at: Location — Address Assessors Map and Parcel ----------------- --- ----------------------- Address G6 + Installer — Driller Address _ Cr3G� Type of Building a-- Dwelling--------------------------------------------------------- Other - Type of Building --- ------ No. of Persons-------------------—_—_____ ----------- Type of Well ° --�'�—�- �FJ % 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 until Certificate of Co "7iance has been issued by the Board of Health. Signed -- date Application Approved B - �� __--___— date Application Disapproved for the following reasons: ------------_-__—_—____________— --_ — - -- --—---------------------- ---- --- date Permit No. e,) y 3 / Issued-- --���--- � date BOARD OF HEALTH TOWN OF BARNSTABLE Certcf rate Of Compliance THIS IS TO CERTIFY, Thaj the Individual Well Constructed (L, Altered ( ), or Repaired ( ) b OW --------------------------------- Installer has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation as described in the application for Well Construction Permit No. c`—! �__Dated 6A/ ZaP THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE-----— - - Inspector------------ — ---- r -------------- No.- -- - Fee i BOARD OF HEAD H TOWN OF BARNSTABLE Applicat ion ArVe[C.Contruct ion Permit OS Application is hereby made for a permit to Construct ( ;'"Alter ( ), or Repair %, individual Well at: Al Location =fAddress {.,Assessors Map and Parcel 19e--)6ae ' tlacr CE- - - -- ------------- - - - wner Address GZIo u Installer Driller Address Type of Building r� Dwelling----—------- - ------------------------- Other - Type of Building--------------------------- No. of Persons_----------------- I Ale- Type GrJ�"i Pam. Type of We11—T--------------- Capacity---� - —_---__ Purpose of Well---�o Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation — The undersigned further agrees not to place the well in operation until Certificate .of Co Hance has been issued by the Board of Health. Signed --- =o-"''.�_-— 21_16(27 1 date Application Approved B =1� -------- Z date � Application Disapproved for the following reasons:-------------------- _______ --_ — -- ---- --- ---- date Permit No. -- Issued---— L -� ----=— - - 1 date ..:lbl:e:r:�..:l:x:+blb!a+r:eaw�iseeaeae:ses:ses:�:eaebeis�.a=aaasa:ieasasasaa:neea�aeaeavasac+asasamasaiaxaasailascaaeilaQa�asr-s:saiaes�aresaxmreasasilair-se:�ae.tae.e� /S BOARD OF HEALTH TOWN OF BARNSTABLE Certificate ®f Compliance THIS IS TO CERTIFY, Tha the Individual Well Constructed ("tered ( ), or Repaired ( ) b � ` Installer i at has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation as described in the application for Well Construction,Permit No. -3�___Dated THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION,SATISFACTORY. DATE--:-------- _ it Inspector-----= ----- $N�Y'.a+6�iwP4i�.1�I.+a�i.K?O!i'=imiSi�i!•!b!f!O!4'!RilalY!i!i?iWQi.!a,AiTi9aW?+61a!>aTa!a!f�blSSBaipi:+K9aHTb.a4i4i?aTi'Tilitb+!i!ai1VTi�:?:l�o'!aTa!64,6y^ilaYiTaHim6�K D�'a"4K�i�a BOARD OF HEALTH TOWN OF BARNSTABLE . Vell Contructionpermit No.o./7.CI Gtl- 3f Fee- �--, Permission is hereby granted /2?J~ftd (AEG __--_— to Construct (Lo Alter ( ), or,Repair ( ) an Individual Well at: No. 6 ac w� J tn/Q J d` a, Street as shown on the application for a Well Construction Permit No._ G�- z- 7,vo v ----- Dated-- Q � — ='= ---—---—------------- Board of<ealth DATE ENVIROTECHLABORATORIES,INC. MA CERT.NO.:M-MA 063 449 Me.130 Sandwich, MA 02563 908(888-6460) 1-800 339-6460 FAX(508)888-6446 CLIENT: Albert Soule LOCATION: 651 Main St. ADDRESS: 651 Main St. W. Barnstable, MA W. Barnstable, MA COLLECTED BY: Desmond Wells SAMPLE DATE. 6/13/2000 SAMPLE TIME. 6:OOPM WATER SAMPLE TYPE. New Well DATE RECEIVED: 6/15/2000 LAB I.D. #. 0006322 WELL SPECS.: NA RESULTS OF ANALYSIS: Parameters Units Recommended Results Method Date Analyzed Limits Coliform bacteria /100ml 0 0 9222 B 6/15/2000 pH pH units 6.5-8.5 5.58 4500 H+ 6/15/2000 Conductance umhos/cm 500 82 120.1 6/15/2000 Nitrate-N mg/L 10.0 0.117 300.0 6/15/2000 Nitrite-N mg/L 1.00 < 0.003 300.0 6/15/2000 Sodium mg/L 28.0 8.5 200.7 6/15/2000 Iron mg/L 0.3 0.790 200.7 6/15/2000 Manganese mg/L 0.05 0.012 200.7 6/15/2000 Volatile Organics See Report. MTBE ug/L 70 2 EPA 524.2 6/19/00 COMMENTS: Low pH indicates high corrosive characteristics. Iron level is not a health hazard. WATER MEETS EPA STANDARDS AND IS SUITABLE FOR DRINKING PURPOSES FOR PARAMETERS TESTED. <=less than Date dl >=greater than onald Sa ri TNTC=too numerous to count borat irector I� 06/19/00 13:36:04 2—> 500 800 6446 Page 002 GROUNDWATER Groundwater Analytical,Inc. P.O.Box 1200 ANALYTICAL 228 Main Street Buzzards Bay,MA 02532 Telephone(508)759-4441 FAX(508)759-4475 June 19,2000 Mr. Ron Saari Envirotech Laboratories 449 Route 130 Sandwich, MA 02563 Project: Albert Soule/651 Main St., Barnstable Lab ID: 33946 Sampled: 06-13-00 Dear Ron: Enclosed is the Volatile Organics Analysis performed for the above referenced project. This project was processed for Rush turnaround. This letter authorizes the release of the analytical results, and should be considered a part of this report. This report contains a project narrative indicating project changes and non-conformances, a brief description of the Quality Assurance/Quality Control procedures employed by our laboratory, and a statement of our state certifications. I'attest under the pains and penalties of perjury that, based upon my inquiry of those individuals immediately responsible for obtaining the information, the material contained in this report is, to the best of my knowledge and belief,accurate and complete. Should you have any questions concerning this report, please do not hesitate to contact me. Sincerely, Jonathan R. Sanford President J RS/pj m Enclosures l i � GROUNDWATER ANALYTICAL EPA Method 524.2 Volatile Organics by GC/MS � Field ID: 0006322 Laboratory ID: 33946-01 Project: Albert Svvle/65 Main St,Barnstable O[Batch ID: v#5-1263-W � Client: [^vrohsh Sampled: 06-13*0 {vnu.noc *omL VOA Vial Received: 061-/5-00 Preservation: MC /Cool Analyzed: 06-19-00 � Wvmx Aqueous Dilution Factor: I � PoXo 1 of it Anal e-'2 � � RL 0.5 '---4 '- - ' '--- / '^~~'^ trans- ' � _ '~'~~~ 7143-2 '"""'-0=" � 0_414 Groundwater Analytical, Inc' P/J. Box lZNl228 Main Street, Buzzards Bay,MA02S32 ' | _----_----- —_--_--__ � / 06/19/00 13:36:56 2-> 500 000 6446 Page 004 GR13UNDWATER ANALYTICAL EPA Method 524.2 (Continued) Volatile Organics by GC/MS Field ID: 0006322 Laboratory ID: 33946-01 Project: Albert Soule/651 Main St.,Barnstable QC Batch ID: VMS-1263-W Client: Envirotech Sampled: 06-13-00 Container. 40ml.VOA Vial Received: 06-15-00 Preservation: HCI/Cool Analyzed: 06-19-00 Matrix: Aqueous Dilution Factor: 1 Page: 2 of 2 CASNurnber' Analyt� — z Concentration _ _Repor Lt ting it 96 18 4�1 2,3-Trichloropropane —L BRL ug/L 0.5 103-65-1 - a-Propylbenzene BRL ug/L 0.5 95-49-8 2-Chlorotoluene BRL ug/L 0.5 108-67-8 1,3,5-Tri methyl benzene BRL ug/L 0.5 1064341 4-Chlorotoluene BRL ug/L 0.5 98-06 6 tert-Butylbenzene BRL ug/L 0.5 95-63-6 1,2,4-Tri methyl benzene BRL ug/L 0.5 135-98-8 sec-Butylbenzene BRL ug/L 0.5 541-73-1 1,3-Dichlorobenzene BRL ug/L 99-87-6 4-Isopropyltoluene BR 0.5 0.5 106-46-7_ 1,4-Dichlorobenzene BRL ug/L 0.5 95-50-1 12-Dichloro6enzene BRL ug/L 0.5 104-51-8 n-Butylbenzene BRL ug/L 0.5 96-12-8 1,2-Dibromo-3-chloropropane BRL ug/L 0.5 120-82-1 1,2,4-Trichlorobenzene BRL ug/L 0.5 ---..__.__. _. . 87-68-3 Hexachlorobutadiene BRL ug/L 0.5 - _.. 191-20-3 Naphthalene BRL ug/L 0.5 87 61-6 1,2,3-Trichlorobenzene BRL ug/L 0.5 QCSutabg to G4tnpQunds Retouery - QC unrili • 77 1,1 Dichlorobenzene-d4 100 % 70-130% 4-Bromofluorobenzene 98 % 70-130% Method Reference: Methods for the Determination of Organic Compounds in Drinking Water,Supplement III,US EPA, EPA-606/R-95/131 (1995). Method Revision 4.0. Analyte list as derived from 40 C.F.R. 141.40 and 40 C.F.R. 141.61,and additional analyte MTBE. Report Notations: BRL Indicates concentration,if any,is below reporting limit for analyte. Repuning limit is the lowest concentration that can be reliably quantified under routine laboratory operating conditions. Reporting limits are adjusted for sample dilution and sample size. Groundwater Analytical, Inc., P.O. Box 1200, 228 Main Street,Buzzards Bay,MA 02532 Department of Environmental Management/Division of Water Resources WELL COMPLETION.REPORT WELL LOCATION GEOGRAPHIC DESCRIPTION Address <,-41 i 44 C444 St r N S E W of (feet) (circle) City/Town 1 G,3 m e}r• b je= Well owner, 6Cr (road) Address S I M S�ro n-M N S E W of (mi.in tenths) (circle) Board of Health permit.obtained: yes � no❑ intersect. w/ (road) WELL USE WELL DATA Domestic Q/Public❑ Industrial ❑. Total well depth 56 ft. Monitoring❑ Other Depth to bedrock ft. Water-bearing rock/unconsolidated material: Method drilled Description Date drilled Water-bearing zones: :CASING 1) From To 4'C) Type Sn 10 Li g A v r+ 2) From To Length___41 ft. Dia(I.D.) in. 3) From To Length into bedrock ft. Gravel pack well: dia. Protective.well seal: dia. Screen: Grout ❑ Other Slot#_-- length____Lj_from!:jL to STATIC WATERIEVEL (all wells) Static water level below land surface_ft. Date , r WELL TEST(production wells) Drawdown 02 ft. .after pumping hr. min. at �1�1 gpm H w measured Recovery "��ft `after_ hr.—min. LOG of FORMATIONS COMMENTS 0 Materials From To i _ Driller , �lr)MO S Y Ian S Yn on c) Firm e ` clne Address 5'RCt.j6 2 r� . City/Town—Q ip In r,. Supervising Driller Reg.# 17!u At.-g�natui�e�of7su—pbfTisMITregiste ed well drille n Please print firmly E ARD OF HEALTH COPY 00/19/2000 RON 14.58 FAX 508 888 0446 ENVIROTECH LASS ¢1001/004 A iiM07XCH GAWRA2-iO ,INC. AfA dM?T ARIL%mod(J i Raw.DO sffiadw*4 P"azw °(8'88 ) : 9 CLIENT. Albert Soule LOCA7 0M. 851 Main St. ADDRESS: 651 Main St W.Barnstable, MA W.Barnstable,MA .gyp BY: Desmond Wells SAMPLy.9�p T E. 6f 3122WO�1yWATM SAMPLE TYPE., New Well DATE RECEWED: &1512000 SAMP L S LI1: DOOM22 WFJJ.SPECS.. NA RESULTS OF ANAL YSIS., Parameters tttift Re V m#n&?dkW Raw& �MOO" t>�Ar�a►�r W Lim its nits caffibmbamrk 1100rnl 0 0 9=B 8f15l2000 PH . PH uriits &5-8.5 5.55 4500 H4� $11512000 Cor.&Vtorwe urnha = 5w 82 120.1 6/1512000 up ma" MOIL 10.0 0.117 300_0 SH 612000 NI&Hs-M nVIL 1.00 0-0.003 ' _0 811&2000 Sodium MOIL 28°0 a.5 200,7 6115M000 Iron- mglL 0.3 0.190 200.7 6115f2000 11f9+rgar+m mg/L 0.05 0.012 200.7 Bh 5P2000 VbhrIW Organics See Report_ MTBE ug/L 70 2 EPA 624.2 6119100 COMMENTS., Law pH indicates high corrosive.characteristics. Iron level is not a health hazard. WA TES?REM SPA STANDARDS AND f5 SUfTAGL.E FOR OR&KING PURPOSES FOR PARAMETERS TESTED OkA4,,� <-zlessthan LIP >=greater than TNTC--too nuMerous to 00unt irate 09/19/2000 MON 14:56 FAX 506 888 6446 ENVIROTECH LABS W002/004 06/19/09 13:36.64 2-3 SUB HHEI 6446 Page OOZ, I5IWLWWATFRGround"ar kvydrvl,ux. P.Q t',uF 1�A9 AlLY1.'ICAL 220M;anStreet Buzzards Bay.AAA a2532 Telephone(508)ng-Wi W.501)759-4475 June 19,2000 Mr. Ron Saari Envir©tech laboratories 449 Route 130 Sandwich,MA 02563 Praeget A&ee4 Sa de/651 Main 5t,,garnstable Lab JIM 33946 Sampled; %-13.00 Dear Ron: Enclosed is the Volatile Organics Analysis performed for the above referenced project. This project was processed for Kush turnaround. This fetter authorizes the release of the analytical results, and should be considered a part of this report. This report contains a project narrative indicating project changes and non-conformances,a brief description of the Quality Assurance/Quality Control procedures employed by-our{aboratory, and a statement of our state certifications. i aiest under tfe pains and penalties of perjury that, based upon my inquiry of fhose individuals immediately wWrsibfe for obtaining the information, the material Lontained in this report is,to the best of my knowledge and:belief,amirate and et mplete. Should you have any questions concerning this report,please do-not hesitate to contact me. Sincerely, ti• Jonathan R.Sanford President JRS/pjm Enclosures Q/19/2000 MON 14:56 FAX 506 888 6446 ENVIItOTECB LABS ¢1003/004 M3119193 13.36:23 536 866 64% Page 663 AMLYTICAL EPA McMod 524.2 Vaiallie Organics by GCfMS Field ID! 0006322 Laboratory ID: 3U46.01 FfajecL Albers SouW651 AU-In St,gamstable gcffi ech ir7: VMI$.t263WW Cllent Emiretech SampleA W13-00 Contains: 40mt VOA Vial RwWved: O6-i5-00 Preservation: MCI I cool Analyzed! 0""0 matrix: Aquarius Driiadon Factor 5 Page, 102 IIC}7 �,. iNtl� "t1 J y.BRL YEA. 0.5. tlpill, hfgrodrdfupnnmvthdne 74-t17 3 8RL uglL v-5 75.01-4 Yirryi Chloride BRL - UFA 0.5 74.63-9 Urunwrivahaft BRL --- -- 75-0 3 Chlorocthane BRL ugJt 0.5 75.6 - - -_frichlomRumniethane BRL _ u L 0.5 75.35.4 1,1-Dirhlomelhene _ BRL --- 75.03-2 Methylene Chlori,3e - _ 6RL -- _ _ugrt -10 1 SS�J 5 trans-1,2-(Nt;WoToe*em BILL �uglt fl.5 163"" Methyl tent otyf Ether(M7BF1 2 ugft 0.5 75-34-3 1,1•Dichloroethane BRL ug1L 0.5 590-2fl-7 2.2-Dichloropropane _ BRL u --_ q.g 156.59-2 cis-1,2•Dichlouoethene_ BRL ug/L 0,5 1 74-97-5 BrottwcbIviomethane BRL - 67-6&3 Chlorr►fdrra ' _-_ ORL ug2 0,9 7i-55:6 1,1,1-Trichlgeeetls;ane _ BRL __ u�rl. t►�5 � 5&23.5 Carbon Tetrachloride 1 BRL u 11 0.5 563-5l36 tr1-Dirhl*m ropene - BRL _ ugJL 0.5 -I 7143.2 Y Benzene BRL ug/L _ 0.5 --I 107.061-2 _112-0irhloropth_ane ---- _ BRL - Ugh.- 0.5 1 79.01_6 Trrchloroethene BRL U0 0.5 7ti87-5_-- 1,Z-01chlaraprapdne _ -BRL ; UWL -- 0.5_- 744rr3 Dibrgmemmtt Ott t _ualL U.5 7W7-4 Bromodichloramethane _ BRL ugtl ( tt•5 10pbf t-01.5 cis-1,3-Dichimpropmie BRI ug1L 0.5 t0$88-3 Toluene BRL _ ligil. t1.5 10061•02-6_ trar&l,3-DKhloropmpene I _BRL_ ug/L 0.5 5 1,1,2-71 ricnibroefhane _j DRt _ ugR. 0.5_ ' 127-1 S-4 _Tetrachiomethem BRL _ �ug/L _0 5 142-18.9 1.3•D6i 0rgpmpang IIRl us'(L - 4•S 124.48-1 Dibromochlommothane_ BRL 106-93 4 1,2-Dibmmoedmne BRL u I7.5 lty8-90-7 _ Chlombemene _ BRL ug/L 0.5 100-20-ti 1,1,1,2-TalraC6l0roethane -BRL _ u�l. 0.5 100.41.4 Eth+�4berrxene _ BRL 0.5 108.38-3/106.42.3_ meta-XyderlandPam-X lane -� BRL uvJl -_ 0,5 _95474 onh4•Xylone' BRL edt. 015 1Q4 4?-S Styrene _ BRL uR/L - 0.5 7S-2 -2 Bromof+orm T__ BRL _ uglL 1 0.5 9"2.8 Isopropylbenzene BRL 41. 0.5 1011.8C*1 Brotntlbca'ane _ BRL •.,_. ug/I. 0.5 i 79.34-5 _ 1,I,-2 TetraChlommi}a,& -- -- BRL ugFL 0 5- Groundwater Analytical,Inc.,P.O.Box 1200,228 Main Street,Buzzards Bay,MA 02532 .0y/19/2000 MON 14:57 FAX 508 888 6446 ENVIROTECH LABS U004/004 SIM 1388 6495 Page 004 ANALYTICAL EPA Method 524.2(ContinuecO Voiatile Orpnics by GUMS Field 11): 0006322 Laborat"ID: 33946-ol p1ofe= AUjW We/651 main st,EINFINIFtable QC batch 10: VM&.1263-W client ftmrotwh Saft4i2d: cemmim-'r. 40ML VOA AIlial Received. Preservatives: He I Coal AnalyzM: 06-1940 Matrix: Aqueous Dilution Farlur. I Page: 202 I grp-r. re g 9&184 1,2,3-Tirldi9ary pTopane 103-65-1. a 711'ropyllw3uene OKIL ug/L 9549-8 Z-CWormluene L *lL — 0.5 1,3,5-TTirntIhyibenzene ugfL_ USA —9 U L —45--63-6 11,2,4Trimohylbannelo. BRL uglL 0.5 fk-qu sec-Outylbenzene, RF— ugrl. 0.5 541-73-1 1,3-DiChlOFdiCnzeWi**" BRL OWL —Ii.-S 99-87-6 4450prapyltofuam BRE Uri 0.5 --Usk 03 BRL u l 0.3 104-51-B ORt 0.5 i7,ibibro -chi�mprcpane 96-12-8 mo-3 BRL UriI 0.5 120-82-1 1,2A-InchlGrobenzene, up/l. T 0.5 87-W3 HoKacblorabzdiirib BRI. u 0.5 91-20-3 f�aphchwene BRL NAP 37-61-6 11,2,3-Trichtemnwine be u-01chlorubenzene,d. 70-130% % MrAbodiftelenmw. Meth otbfur flic DVotarramjun of Organic Compounds In DdnkingWaM Supplement fit,USEP& EPA 6=9YI371(1993). Method Revision A-0- 40 C.F.R.14-.1.63,and add4ional analyte MTSE. Warl N6110iono OR Iftelleamb comintrailan,if any,is bellow irr;wrvag limit for anaiW. RLipurting limit if Me lowest cmren rdi*n that cin be a4iaWr qurWwd under murine Ilfboratery oixyging conditions. Report(ng[frnil5 are adjusted firs jiarniW4 dilution and sample if2e. Groundwater AnAlYlliQd,IFYz., P.O.Box 1200,2z8 Main Street,SauArds Day,MA 02532 David B. Mason, R.S. DBC Environmental Designs June 14,2000 Ms.Donna Miorandi,Health Inspector Barnstable Board of Health 367 Main Street Hyannis,MA 02601 Re: 651 Route 6A,West Barnstable, MA , Owner: Albert Soule . Dear Ms. Miorandi, This office has been asked to clarify with you the basis of the repair septic design for the site referenced above. From the initiation of this project,this office was informed by the owner that the house was approximately three bedrooms. Due to the size of the house and the need to meet the intent of Title 5,this office conducted a walkthrough to determine the actual number of bedrooms based on Title 5's definition of a bedroom. Based on that definition,this office determined that seven bedrooms met the intent of Title 5. The bedroom count was determined on the basis of Title 5's definition with consideration of the witnessed floor plan and proximity to bathroom facilities. During the percolation test at the property, I informed you of this bedroom issue. You concurred with the bedroom design and stated that the design should represent such as to meet the need of Title 5. This office wishes to clarify this issue and the intent of the repair design. Due to the short term failure of the existing overflowing system,the repair designed by this office must meet the intent of Title 5 to insure a true adequate design representative of the actual or potential use of the property. Thank you for your assistance. Please call this office with any questions. Sincerely, David B. Mason,R.S. cc: Albert Soule,651 Route 6A,West Barnstable, MA 51 Service Road, East Sandwich, MA 02537 508-833-2177 Propwq Address 651 Route 6A(Main Street) File No .661RTE6A.BAR City West Barnstabk County Barnstable State MA Zip 02668-1127 Borrower Albert L Souk Lender/Client Compass Bank tJC Address P.O.Box 1902,Now Bedford,MA 02741 Appraiser Name Thomas G.Kokolledk Appr Address 450 Pond St,S.Weymouth,MA 02190-1248-26 Comments: 9.00, 27.00' 20.00' C i Bath Bedroom - - Bedroom 15.00' Bedroornk4,C] C 29.00' C 19.00, Bedroom Bedroom 14.00' 37.00' Attached Shed f S4udf v 10,W, Storage Area 13 X 1 i c� Bedroom I 9.00' 20.00' Porch j E . Bath Sitting Family Room Dining ROOM Kitchen 15 W en Room 29.00' ____.� C 14.00' Bedroom Living Room C 11.00' 14.01E Foyer 8.O01 15.00' 8.00' ` Pag RMI Eptl.Apptdod i Mope Sw.in AM 80n WARE e0G•e%NU GIN File No 651RTE6A.BAR ---- --- ------- ---------- Property Address 651 Route 6A(Main Street) _ City West Barnstable County Barnstable State MA Zip 02668-1127 Borrower Albert L.Soule Lender/Client Compass Bank L/C Address P.O.Box 1902,New Bedford,MA 02741 Appraiser Name Thomas G.Kokoliadis _ Appr Address 450-Pond St.,S.Weymouth,MA 02190-1248-26 'Comments:. --- — -- — 9.00, 27.00' 20.00' Bath ;) Kitchen I. Bedroom 15.00' Bedroom=� --C y.:._ C 29.00' 19.00, Bedroom % Bedroom 14.00' 37.00' 14.00' Attached Shed Storage Area C Enclosed Porch Summer Kitchen 9.00' 4.00' 20.00' E Porch d 1, 1 Bath Sitting Family Room Dining Room = Kitchen 15.00' Room r=AR =_ 4 29.00' 14.00' Den = Living Room C = 11.00' C 14.00' Foyer 6.00' 15.00, 8.00, Page 1 of 3 Real Estate Appraisal&Inspec.Serv.Inc - APEX SOFTWARE 800-858-9958 Generic2•Apexll `f AISSSOR'S, MAP NO. PARCEL ' r _ - LG CArioN _ W A G E PERMIT NO. el� / VILLAGE ,j--, A- I N S T A LLER'S NAME " A ADDRESS B U I L D E R OR OWNER eAo � DA T E P E R M I T 1SSU E D1 DAT E COMPLIANCE ISSUED e 'Ad `�'� ,SSESSCpy P11A,P No: PARCEL NO.. No..----b--•--.......... Fps ......... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH GW ....................OF......a�4!'ns lo..---------------._...------------------....---------- Appliratiun for Uhipaiitt1 Works Tilmitrnrtiun Prrmit Application is hereby made for a Permit to Construct ( ) or Repair (44 an Individual Sewage Disposal System at;- � ca�O ....�►`+l.._ —b �° �....&naA .�45.........W..... ............................•.................•................................................... Locat' n-,Address � ......................l- ot � ...!2u ................................. (� n O ner �.� p Ad ress .... .. ............. Installer Address Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Oth er—Type of Building .............. No. of persons....._....__............_... Showers — Cafeteria a' Other fixtures ------------------------------------------------------ W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. 1:4 Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ Disposal Trench—No. .................... Width-------------------- Total Length.................... Total leaching area--------------------sq. ft. Seepage Pit No...................... Diameter.................... Depth below inlet.....:.............. Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) '-� Percolation Test Results Performed by..............................•---------------•••-----•-•-------•-•---•-.. Date........................................ Test Pit No. 1----------------minutes per inch Depth of Test Pit.................... Depth to ground water------------------------ 44 Test Pit No. 2-•_•-_--____-...minutes per inch Depth of Test Pit.................... Depth to ground water........................ P4 ----------------------------------•--------•----•----------•---....•---•------......--•-•--•-----•...••••-----•-•...........---•-•------•--._.._............. 0 Description of Soil........................................................................................................................................................................ x V ------------------------------------------•--------••----------•---•------•-••----------------- -------------------------------------------------------------------------------------•-------- ----�OOe..$. L/- -f. ...... r U Nature of Repairs or Alteratio s—Answer when pplicable._- ..!.!kT4---�pC�O- �Q�px,-� ¢4� ,--pjP_ _�•-•--_. Li ne �'�.'' l�-a '�" 1 PAAr,_i'�_.....---ET,��+�= �- -----------•............... Agreement: The undersigned agrees to install the afor edescribed Individual Sewage Disposal System in accordance with the provisions of i i i p J of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has beei�ed,by the board of 1 ealth. igned u . ..... ...... -8 &� Application Approved B ............. _._.. .___. ............ PP PP Y ....... -•-- -- •.. Dat v Application Disapproved for the following ress -------------------------------------------------------------•----------------------------------•------•-------- ...._....-••----------------••-•.._._......-•----••------....•-••----------•-••-•••------•....•-••----•-•------•-•---------------------------•--...----------------------------•-. --------------------- Date PermitNo......................................................... Issued-....................................................... s Date 1vo............ 65� Fxs.....r�l o.............._ THE COMMONWEALTH OF MASSACHUSETTS BOARD OE HEALTH c7t.1'r ti CRl1 ;c I 1............. OF... ,:, ....�...... '.... . ................-----------------•---.._......._......_...----•-•-•- Appliration for Disposal Works Tonstrurtion Permit Application is hereby made for a Permit to Construct ( ) or Repair (-%k) an Individual Sewage Disposal System at: 4 #aW-----••--...... ..........-••---------•••----•.....-------•-•-•-----•---•----•-......•--- Loca'on-Address ► or Lot No. `:�T 1•:A�t�vS �t Ce c; ................. ,u t =--��•--�' lr riss 0 1�-•-------------------------_•.... Owner e�rAddress r ............•--••--•....................••••--•- -•-•------- Installer Address �t d Type of Building Size Lot................:...........Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) pal Other—Type of Building _-______-___•_______....... No. of persons............................ Showers ( ) — Cafeteria ( ) Q' Other fixtures ...................... . . W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. P4 Septic Tank—Liquid capacity............gallons Length:................ Width................ Diameter-___-_..-___•__- Depth---------------- Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area--------------------sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tanl� ( ) - Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water_-___________-___---_--. (i, Test Pit.No. 2................minutesper inch Depth of Test Pit.................... Depth to ground water........................ a •-••--•--•-••••••---•---•---•••--••-••••--•-••••-----•-•---•-•-.....--•----------------•--.......---...........•••••••••••••-•-...._......----..........---- 0 Description of Soil--------•----------•---------•-•----....----•----------•..................•-•----------------------------------------------------------------••-•-......-••---------•••- x _ W ...••--•...__../D�� ' ``......�'` •-----------.....--->-------------------------- V Nature of Repairs or Alterations—Answer when a1Dplica1ble -_'2 '.�tC ---. ��� 1�_...c.4 :�� 1v ........ v. _ - Agreement: b The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of liml.4: ;of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has.been-issued by the board of health. / / igned. _... ssU b Af t "��*!v??aGH ---•------- ------ ----------- � ... � .. ...•.... pate bb ApplicationApproved By................ -�-- -- ----------......... ------•-•----------•------- ••... O'.... Application Disapproved for the following real n -------------_--------•-- •--------------------•-------•-------•--......_.....-------------•--------•-----••------...._..........--••-•-•----------------•----•••-•---••-•--••-•-•-•••-••--•----•-•---•-•-----•••••••--•---•-•---- Date PermitNo......................................................... Issued....................................................... Date - — tl�i5 THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH CTrrtifirtt#r of Tomplinnrr TIJ S IS TO tRTIFY, That the Ind* id 1 ew e isposaLSystem constructed ( ) or Repaired t Installer -------------------------------------------------------------------- has been installed in accordance with .the provisions of TI T IE 7 of The State Sanitary Code as Described in the application for Disposal Works Construction Permit N o....0S....�..a_.� dated_...--� _�! _ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT YHE SYSTEM WAL, FUNCTION SATISFACTORY. DATE........... ............................................. Inspector........ .. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH S .......Ln......... .... l-e............................................... aU BYO t..V.:..\1......... FEE.........`............ Disposal Nor s , Permission is hereby granted . .:. .. -.---------------------- •• ..................... -----•-•-••• =--••----•........................ to Construct ( ) or Repa an Individ al Sewage W silos System , atNo. C7 ........(D. ....------------------.-----------��-....................................................................... Street as shown on the application for Disposal Works Construction Per* No.................... Date .......................................... 1 # � •-•••-•--•.............................. Board ox Health 'SATE............... .. ..... . .....•----•--- FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments c 9sV 651 Main st Property Address 4? Sheila Bournzal/ Bursley Manor ►-� Owner Owner's Name co information is required for every Ma 02668 10/12/16 R� page. City/Town State Zip Code Date of Inspection C.1 m Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: key to move your cursor-do not Michael DiBuono use the return key. Name of Inspector DiBuono Sewer and Drain ,gb Company Name 8 Johns path _ Company Address erwn S Yarmouth Ma 02664 City/Town State Zip Code 508-364-9587 S103522 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 10/13/16 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. l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of17 r� 40eV i Commonwealth of Massachusetts Title 5 Official Inspection Form — Subsurface Sewage Disposal System Form.- Not for Voluntary Assessments \fie 651 Main st Property Address Sheila Bournzal/ Bursley Manor Owner Owner's Name information is Barnstable Ma 02668 10/12/16 required for every page. City/Town 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: System contains a 2,000 GI septic tank as well as a concrete distribution box and a leach field 52'x20'x5' 13) 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 651 Main st Property Address Sheila Bournzal 1 Bursley Manor _ Owner Owner's Name information is Barnstable Ma 02668 10/12/16 required for every _ 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): ❑ 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): El 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 a Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 651 Main st - Property Address Sheila Bournza_I/ Bursley Manor Owner Owner's Name information is Barnstable Ma 02668 10/12/16 required for every — page. City/Town 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 1/2 day flow t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 651 Main st Property Address Sheila Bournzal / Bursley Manor . Owner Owner's Name information is Barnstable Ma 02668 10/12/16 _required for 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. 15ins•3/13 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 651 Main st Property Address Sheila Bournzal/ Bursley Manor Owner Owner's Name information is required for every Barnstable Ma 02668 10/12/16 - page. City/Town 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 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 7 Number of bedrooms (actual): 7 DESIGN flow based on 310 CM 15.203 (for example: 110 gpd x#of bedrooms): 770 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 651 Main st Property Address Sheila Bournzal/ Bursley Manor Owner Owner's Name information is Barnstable Ma 02668 10/12/16 _ required for every page. CityrFown State Zip Code Date of Inspection D. System Information Description: System contains a 2,000 GI septic tank as well as a concrete distribution box and a leach field 52'x20'x5' Number of current residents: 2 --- Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (include laundry system inspection El Yes ® No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage 336 Gpd g ( Y 9 (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•3113 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 /V 651 Main st Property Address Sheila Bournzal / Bursley_Manor Owner Owner's Name information is required for every Barnstable Ma 02668 10/12/16 page. City/Town 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: 6/13/16 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 651 Main st Property Address -- -- - Sheila Bournzal! Bursley Manor Owner Owner's Name ---- information is Barnstable Ma 02668 10/12/16. required for every _ page. Cityfrown State Zip Code Date of Inspection D. System Information (Cont.), Approximate age of all components, date installed (if known) and source of information: 16 Years Were sewage odors detected when arriving at the site? ❑ Yes ❑ No Building Sewer(locate on site plan): 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): Depth below grade: .5 + feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) 2000 If tank is metal, list age: --- years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: _ Sludge depth: _. l5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts _ _ F Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 651'Main st �y Property Address Sheila Bournzal / Bursley Manor Owner Owner's Name information is required for every Barnstable Ma 02668 10/12/16 page. City/Town 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 Scum thickness 3" Distance from top of scum to top of outlet tee or baffle 42" Distance from bottom of scum to bottom of outlet tee or baffle 1" Sludge stick How were dimensions determined? Tape Measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): No evidence of Ieaking,Tees and or baffles in place at time of inspection. 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 l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 i Commonwealth of Massachusetts W Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments .' 651 Main st Property Address Sheila Bournzal / Bursley Manor Owner Owner's Name information is Barnstable Ma 02668 10/12/16 required for 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.): Tees are in place and levels are normal. _ 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 l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 I Commonwealth of Massachusetts -- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments a 0 651 Main st Property Address Sheila Bourn_z_al/ Bursley Manor Owner Owner's Name information is required for every Barnstable _ Ma 02668 10/12/16 _ 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 Level and at normal level 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.): 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.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts u Title '5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 651 Main st Property Address —------ --- --- -- --- — Sheila Bournzal/ Bursley Manor Owner Owner's Name information is required for every Barnstable Ma 02668 10/12/16 _ page. CitylTown State Zip Code Date of Inspection D. System Information (cons.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: - ❑ leaching trenches number, length: — --—- � leaching fields number, dimensions: 52'x20'x5' ❑ 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.): No break out no ponding 7. 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 g-oundwater inflow ❑ Yes ❑ No 15ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth.of Massachusetts Title 5 Official Inspection Form = Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 0 651 Main st Property Address Sheila Bournzal / Bursley Manor Owner Owner's Name information is required for every Barnstable Ma 02668 10/12/16 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.)-. No ponding no break out 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 CoinmonweaIth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 651 Main st Property Address Sheila Bournzal/ Bursley Manor Owner Owner's Name information is required for every Barnstable Ma 02668 10/12/16 _page. Cityrrown 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 a:tached separately 15ins•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 651 Main st Property Address Sheila Bournzal/ Buirsley Manor Owner Owner's Name information is Barnstable Ma 02668 10/12/16 required for every 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: 10+ ft 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. 3/9/2000 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: Test hole data on plan 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 Assessing As-Built Cards Page 1 of 2 �"— TOWN BARNSTAB Cr LOCATION M SEWAGE# a &b- VILI AGE t7IQ � ASJSESSOR'S MAP&LOT r'O-51 INSTALLER'S NAME&PHONE NO. IS i��P12 N l . c��Q 1": '20% SEPTIC TANK CAPACITY LEACHNG FACILITY:(typo) rr r:/d (size),,L NO.OFBEDROOMS 7 BUILDER OR OWNER Y` Sa PERWTDATE: —? x' COMPLIANCE DATE: Ohl Intl) Separation Distance Between the, ,/�' Maximum Adjusted GroundwateAble end Bottom bf Leaching Facility !-�t9 G110 Feet- Private Water Supply Well and Leaching Facility (If any welts exist on site or•within 200 feet of leaching facility) f l� Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leactun facility) �J O Feet Furnished py, > i . i • O http://www.towlnofbaiiistable.us/Assessinp,/HMdisl)lal,.asi)?Innaptnal=l 56057&sea=1 10/3/2016 Commonwealth of Massachusetts ' W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 651 Main st Property Address Sheila Bournzal / 3ursle Manor Owner's y ------- -- wner's Name information is Barnstable Ma 02668 10/12/16 required for every _ page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ❑ Inspectior. Summary: A, B, C, D, or E checked ❑ Inspectior 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 15ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 No.- - -- -- ------� Fee al ------------ BOARD OF HEALTH TOWN OF BARNSTABLE Application-*r Well Congtructi nj3prmit 6W Loc 0 �l Application is hereby made for a permit to Cons t uct ( ), Alter ( ), or Repair ( )an individual Well at: -------------------------- — -= —�t—-- —� - -- --- - ----- --- - ---- -— ------------ Location — Address Assessors Map ar d Parcel --- -g -�5-- - --- - -� t__- -- ----- -- - Own r ddress � - .... .... ------... -..... -............ -- Installer — Driller Address Type of Building Dwelling------------------------------------------------------------ Other - Type of Building------------------------------- No. of Persons---------------------------------------- ,r 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 until a Certificate .of Compliance has been issued by the Board of Health. -/ < ?-> Signed ----- —�-- ------ - ---�------------- eq --/®------------- date Application Approved By -- ---- --------- date Application Disapproved for the following rea s:-----------------------------------------------=--------------—----- --------- date Permit No. - --- Issued--F ---------------------------------------- - ---------------- date BOARD OF HEALTH TOWN OF BARNSTABLE Certificate ®f Compliance THIS IS T CERTIFY4VIe Individual Well Constructed ( ), Altered ( ), or Repaired ( ) by---------- - — — - -------- --- - --------- ------ I -- -- - --- ---- ------ /.)a_ a t- -— — ®-- - - -- - - -- --— -- - --- hasbeen installed in accordance wit the provisions of the Town of Barnstable B�a e�al vate Well Protection Regulation as described in the application for Well Construction Permit No. '-k1 --Dated --- — THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE- ---- --—-- -- - —-- Inspector---------------------------------------—--- ------------ r ,`f��.-,«->,... ,._ _...cr'+' - i..,,, r ..s:.,,,,�.. .. Y I►. s,y"T','"�� N - _ ?J _tM1.. 'r� ... No.- - -� Fee.-- BOARD OF HEALTH Y TOWN OF BARNSTABLE ZippIicatiow-*rVeil Con0truction ermit 'Application is hereby made for a:permit to Construct ( ), Alter,( ), or Repair ( )an individual WellTat: mell,--- Location — 'Address ! "` Assessors Map a d Parcel r Y t Own r Address - -- ------ - - - --- -- A --------- _ --------------- Installer Driller Address Type of Building Dwelling-----—------------------------------------------------------ Other - Type of Building--------------------------------- ,... ,'No. of Persons---------------------------------- j,� Type of Well- --`- - -- -- - ------- 4. i YP - --- Capacity--------=------------------------------------- : Purpose of Well--------------------------------------------------------- � Agreement: y The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The,. Town of Barnstable Board of Health Private Well Protection Regulation - The undersigned further agrees not to ¢ place the well in operation until a Certificate .of Compliance has been issued by the Board of Health. iSigne -�---------- � date Application Approved By - date 77 f Application Disapproved for the following rea s: ------------------------------__—_______—__-___—_--_ I , - —-- -_ ------ - - ---- - - - --�- -_ ="=---------------//Yo --- - - w date --- Issued -- / Permit No. I , date ,1 r BOARD OF HEALTH /J TOWN OF BARNSTABLE a Certifirate Of Compliance V,. THIS IS TO ERTIF,Yb a Individual Well Constructed ( ) Altered ( ) or Repaired by---------- - - - - ------- - - ----- --------------- --------- �. In talMer at- — — �, -- - ------------------ --------- ------------------ --------- has been installed in accordance wA the provisions of the Town of Barnstable Boar f Health ,rvate Well Protection f i 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--- --------------------------------- ---- ' t BOARD OF HEALTH TOWN OF BARNSTABLE' VCR Construct ion Permit No. ------ -- .-- /'� Fee-- - ------ Permission is hereby g 'nted _-- ---------_-------------- -----____-- { to Constrict ) Alter ( or Rep 'r ) a In ivi 1 �f�,�t: No. " - - � - ------- ----------- ------------------=----- ---- Street as shown on theaapph'c�at' for a.Well Construction Permit !-- No. — _- _ -- - - Date - - - -- -"I---------{------------- O Board o H Ith v DATE—1-- — - --- -- ASSESSORS MAP : TEST HOLE` LOGS ?P�O�TR5CIC, PARCEL : SOIL EVALUATOR FLOOD ZONE : ��OV46� C, :7- W I TN E S S 14 M 1() DATE: REFERENCE :- lot 6P PERCOLAT ION RATE:' C>(-, TH- I TH-2 47.11 -i_u veo -5-#Vp4f 4 5 le cVf 4q, W-42 )4 t 447 18 1 l - 7 7 I u - ,SY7 LOCATION M I A P 14 —7 '5 IL7 6<0; - 21 461 )H�F- i�. ol,� ;�,/4T. Zo4ty /co zo 27t 114 r z-is; F=n<5 i v- =5 z%f->zc>>11 Z?-" IAITF, i;-:?> ------------- -ly ee SEPTIC SYSTEM DESIG' N' FLOW ESTIMATE ------------- 2-r-, r GAL/D'AY 7>J- -?V�op BEDROOMS AT ) ID GAL/DAY/BEDROOW 12--k: 00 Sm M17 0\ "- '�/5 7 4 EPTIC ANK I-r-o'Al 16V�4 -T C-1 -,- n avipaL �JOT CD 0 2 DAYS GAL I—OGAL/DAY C7) x USE 9�-MGALLON SEPTIC TANK UIL ABSORP ION 4 L 4- rim -L;;P 7 -0c) W)r;)F- 5?1 )11 5 (IN 4t �s 4s�-2 vlc-,e� e-7- SIDE AREA �JL71 qLLOWer--, !z, I � :-� BOTTOM AREA: ------------------- j 2 _T TOD V ry —zf,� N zcz- V-7 S E P T,�I C- SYST.EM �--,.SECT., ON ,, 4� �1�celo e, Qv Mow-,, lFh �j Av tr Ole' ' E. l;z X V/ D--BOX Ilk 5 2-cX)D GAL SEPTICJANK F- 11 N F 41-1-11 T (bTEP 41bl A�o L 410-7-�=- A15 /4%e.!5 A.1 �4;r 7 -7T -"9 T T7 vf ---ff ............ 7-e DAVID 14ARRY DAM LANTERY, JR. #1 No.2657 + z- % VA TE -AND SEWAGE PLAN JZ� p it 'LOCAT i 0 'A/ N PREPARED FOR : �qL8ECr % 6 ZT qc-�j z:)k)/c ---Q _-)3-- J -T �o -,-- - -- - - SCALE': 4 DAVID B . MASON 'R-4S DATE: DBC ENVIRONMEN�Al- DESIGNS DATE HEALTH AGENT EAST SANDWICH . MA ( 508 ) 833- 2177 -pi 7T 0 > 1;aL Y2�20-12 ;�v " i i .r"'.. __,, +.. ,<✓•",., +"s'✓ ^�-1.r 'r+. ry-y,�,,; r. '^v.!^' '-v^ "-"-_.—.... +.,xz+n.K- :'^-.-s•.• �".r..i^"= `: "'ca+4::ti}" - _ . f _ +Ae:c - . _,_. -\ ', :....ter•'•^ ... ., Y ASSESS ORS MAP : (Q_ ��,----- : ---- TEST HOLE LOGS _ - ----- 1 PAR CE L . - — --------. — � L EVALUATOR --- ----- OOD ZONE: _. � � :': Z Z FLOOD �DW E C� '�rt� ._. 1'L _ �_L_ _ W I TNES S : 4lA --- —- b _ DATE . 1 - - - v REFERENCE : t ---��-- _ �._ ., _ _ r x .�,` 1,� ,/fir• ' -ram PERCOLATION RATE: L / �1 :, . �� � F -! W� 1� -. �Q►+"I .1 6 I t -- . TH � C. y ' "'� ,A s - ��w� `� �s , �« i)- (S ��A�trl � w � � �}wa �'`�� _ 18r� /O Z z' , � 5�_ - u 27 M .� �- L% Q - _ _ �-I Hai'; _ c 1��-1 U ,r �.. � / - - • L 0 C A T I ON MAP L�{�I.�1 ----- / _ �,4T Zo�� _ _ LoWq z 7/4 b Z. C3 - -- --------- _ r _ r _ 71 �1�kl A4 _- i� _ . e�_ tiS_ � .. _ QC . roc•3 ---- ---- -----— - - ---- —- — y} ` �xisji�� SEPTIC SYSTEM DESIGN U C,�c :�.� ►2^ P . _ � � �,.� I� �. tea,i- � _: �;..--� `i: �x�sJ-�� _ _ � _ � , - �--------•P:-J.- -.._ -_ �I�j i2►���►._ .._ _ __ _.__ _ __.._- - FLOW ESTIMATE rv, �. - ., � � _. M ' � � L BEDROOMS AT IIO GAL/DAY/BEDROOM(� OM -�700AL/DAY �J 0� r�1A SEPTIC TANK �4 y yC` N I , �RDP Ca I j; � ..., _- GAL/D _ }} C4 s AY x 2 DAYS i O GAL j Ct USE 7�GALLON SEPTIC TANK 7 T t SOIL ABSORPTION SYSTEM - p � 16T/� • `-'---- ' t� ,.•� _ . ---^`' '_ _.. � 70 w�r)� x �,�1--o�-I k G.� Dt.�Q ���9�f-�` '�a��%'1 t `'�� ,� t��--(c1`�; ��.�.:� z:..,. .;.�.,..1 �,�,. �( o - - AREA wcT 'A ' r / /-Za�GS 5 �• BOTTOM AREA: �EA: - 2 ,5-z x 77 - - It 12 ff,� ; °� I I ,Y �-�.� lot --�, _ � -- - �' 11, E , _-- � y, � .. • � . � - SEPT 'I C SYSTEM S E Q �_ -ems ... r�. �,\ •, ': r.r- � �r ! t r Y �, 7� • '^ s l - T ' `j r .:_. .,r ..•,,t_ -n,� ::., ..��- t ."„., , �G c-, .. ?.'�,JfJ� � 1 ch I Ir ("o0 I �- 23� ► s �s - of � r '� � �3,8� _ e - r,. tea•' '! r� D BOX , I 2C�l�GAL �• INui m d °I3,3�- SEPTIC-TANK Ley C�r-:�5 Aq - — _ 0 g2vl5 - -_ -�Cp'S-L - - ' Itz cF '4Tj 51`iLSS - All .so1G,s /"4 _ �rzgsT7 �Z-c y ,= -"--7v-4 ram) Tl- ---- ATE - --- -tea� ''-=�- �•� .,,, ,,.•„�' •=`4"-`''' : t: 2A�} DAVID OF MASS l/�� 1E366 HAR _ `!� �7 , EARL - N � 8 �►f A\ v .2657 E I 4 FGrS , •. —�, � � 9 arc � :a. .-..__,.__ - I` ' - Y - - -- - -- - `;: S I TE AND SEWAGE PLAN i , -•, - - `, -LOCATION GJ -- PREP . q,-€E� j� I ABED FOR • �c"XJL,� y -_ - -__ — SCALE' A I D B . MAS 5 DATE: - D V 0NR . - DESIGNS DBC ENV I RONMEN AL ` EAST SANDWICH . MA �?. F a r^�r <g�+.T % ; 'i�Jt DATE HEALTH AGENT r ( 508 ) 833- 2177 - - --- _ -T „ -- 4 ASSESSORS MAP : TEST HOLE LOGS ` PARCEL : � ' SOIL EV ALUATOR : ---._ _- ' FLOOD ZONE : -- WITNESS : JA � 1 l,_)rT , - v� REFERENCE : ( _ C' I���O � �► ,bl - DATE : PERCOLATION RATE: 14 7 kv •, . TH I TH 2Af_7�� — _ - 0,7 ��(1c�.� LOCATION MAP &'17/- z1sT7 � �� �.-o� 1,-1�1 ram•, �t�tl�l�i14�, 441 ��-k 6 +., 2 I - >' 13G� 7/`T O - lC �, _ �} 1�i g� AA IV ICH mil} 240 ,$,�,.�°t.'k51.;..".'9` tv� � � � _...GlvfY�_ _._� _-......._ -._.._ - ._.' J��.Ze ' •J-J..__��.ti/ ' I. _ SEPTIC. SYSTEM DESIGN � 1 �./ 2�9►Lz � ESTIMATE �P� 1 w � - - _ - - - FLOW'EiT I MATE A . ._ 7 BEDROOMS AT 110 GAL/DAY/BEDROOM -� GAL/DAY flnP I C TANK GAL/DAY x 2 DAYS - 15 D GAL -USE �z�GAL•LON SEPTIC TANK .- \ SOIL A13S0 PT II tON SYSTEM wire x 5"1_DH x �-pnP 4E'j9Grf x ray ---- — io' r►�J, I �,, /o �2 Z o SIDE`AREA: 1$ 7 C\ POTTOM AREA: �c��X 5_Z' X d,7 = 77 s Q f y 6 2 IG SEPT I C. SYSTEM SECT I ON �� w/sue eia 2 u�y z ��: z of t 11 zi A o _ !i 9 8 70 1 D � ._� Cox 5-Rw 4►�s $>a ,�2 _._r � _ < 1 _. `13 i G �' `\ r �5 0��' 71 �L "" D BOX � ,r ,� _ C 3:56h z�GAL NwTu SEPTIC TANKS M FZ L.zYtE C ��� AT o ��� Fiti/� 4. '� '7�C ? '�3C> 15'C j�` .r '►�� ul► �I1.�' '✓ C r_ T - . ` SITE AND SEWAGE PLAN �H OF 1 s /G M�? _ 2 g s?7 .1 F � 7� 5._-_._ s L O C A T I ON : lotTl C-�9 �J�l hl S7; DAVIo \. `'act /cc/ �sE�77� . . �s�t�c`/ - Gc.��"i ��9► WZ5B. T19�3 Q MASON PR A R E D FOR / �' 5 ' �../DGCJ - SCALE•1�� Q ?� b DAV I D B . MASON RS DATE: DBC ENVIRONMENTAL DESIGNS git EAST SANDWICH . MA DATE HEALTH AGENT 508 ) 833- 2 177 w=.rwe.. >u3's^.. :€.,1Y!f'•r.` w'arr;ygn'wa. ti 'W!^ 9w"!n',`,x ^.Y.«-_...srt+M.'"`f .,;:::`'»'*'""+4" •..,..._ . .. .. -.-.. -- __ - ___._ i .__ _____ _ -. TOP FNDN. AT EL. 1 g.65' SYSTEM PROFILE TEST HOLE LOGS ACCESS COVERS TO WITHIN 6" OF FIN. GRADE (NOT To SCALE) DANIEL A. OJALA, SE ACCESS COVER (WATERTIGHT) TO ENGINEER: MINIMUM .75' OF COVER OVER PRECAST WITHIN 6" OF FIN. GRADE 2% SLOPE REQUIRED OVER SYSTEM PEGLENN HARRINGTON RS WITNESS. , AG 2" DOUBLE WASHED 1/8" - 1/2" PEASTONE FEB. 6, 2001 18.5 Rio RUN PIPE LEVEL DATE: 18.69' c FOR FIRST 2' PERC. RATE = 30 MIN/INCH ** Al (EXIST.) EXISTING 1000 y9�aF Q GALLON SEPTIC 17 0't II & III LOCUS TEE 22.5 CLASS SOILS P# 9938 TANK (H- 10 ) ZAWL FlLTER Z1.2' **ADDITIONAL (SIEVE) TESTING PERFORMED BY GEOTESIING EXPRESS INC., ON RE-USE �WT 21.37' _� �b ��� MIN 6' �o B HORIZON (SEE ATTACHED RESULTS) 6" CRUSHED STONE OR MECHANICAL suMP o 21.08 o ROUTE 6A COMPACTION. (15.221 [21) 8a 0.58' co DEPTH OF FLOW = 4 ( MIN % SLOPE) ( MIN % SLOPE) 00 `21.5' ( ELEV. v TEE SIZES: 3/4" TO 1 1/2" DOUBLE WASHED STONE 0" 19.5' INLET DEPTH = 10" A � OUTLET DEPTH 14" LS LOCATION MAP NTS 3» 10YR 3/2 19.25' FOUNDATION , PUMP , LEACHING 4' EXIST SEPTIC TANK B ASSESSORS MAP 156 PARCEL 11 5 CHAMBER 4 D BOX 14 FACILITY 5.3'* 8.4' Perc LS WATER WEEPING AT 24" POND EL. 13.1' �O * TITLE 5 VARIANCE REQUESTED: PERCHED WATER EL. 17.5' 40" 10YR 6/6 16.17' 15.415 (2): REQUEST VARIANCE TO ALLOW 3.1 FEET OF NATURALLY OCCURRING PERVIOUS MATERIAL BENEATH LEACHING -I- EDGE pF BOTTOM B LAYER EL. 16.2' AREA POND EL. 13.1' BENCHMARK TOP OF, CONCRETE ALARM AND CONTROL PANEL C BOUND ELEV = 20.0' TO BE INSTALLED INSIDE BUILDING. ALARM TO BE ON INV. IN 16,9' SEPARATE CIRCUIT FROM PUMP 1000 GAL. H-10 S/ 2' PRESSURE PIPE TO D'BOX SILT LOAM ALARM ON 700 GAL.+ SLOPE TO DRAIN BACK TO PC TO SILT r � FLOAT SWITCH RESERVE WEEP HOLE CLAY LOAM SETTINGSi PUMP ON HECK VALVE p 4' WORKING RANGE 8' . 1 ZOELLER 'WASTEMATE' O Q 4' SUBMERSIBLE MODEL M282 1/2 HP PUMP 41 PUMP OFF 8' SYSTEM (OR EQUAL) NOTE: WORSE SOILS AS GO DEEPER -\ µ w 2 6" CRUSHED STONE OR o cep COMPACTION 2.5Y 5/1 o� PUMP CHAMBER FACTORY WATER-PROOF N S (NOT TO SC&E) 228" 0.5' NOTES: Rv� \ SEPTIC DESIGN: NOT ALLOWED APPROXIMATED FROM BARN. GIS MAP (GARBAGE DISPOSER IS ) 1. DATUM IS _ 220 NOT AVAILABLE 1�4 LE \ \ `DESIGN FLOW: ?_ BEDROOMS (110 GPD" - GPD 2. MUfNiCIPAL WATER IS L=62.83 USE A 220 GPD DESIGN FLOW 3. MINIMUM PIPE PITCH TO BE 1/8" PER FOOT. R=40.00' ,'; Extsr LEACH 'AREA SHEDS SEPTIC TANK: 220 GPD (2-) = 440 4. DESIGN LOADING FOR ALL PRECAST UNITS TO BE `AASHO H- 10 .... � a (ABANDON 5. PIPE JOINTS TO BE MADE WATERTIGHT. 23.3' ---- ( 6. CONSTRUCTION DETAILS TO BE IN ACCORDANCE WITH MASS. PROP. 40 MIL LINER, SET 5' OFF USE A 1000 GALLON SEPTIC TANK (EXISTING) LEACH FACILITY AS SHOWN. TOP EXIST. SEPTIC TANKU3 \ LEACHING: ENVIRONMENTAL CODE TITLE V. ELEVATION AT77522.5', eorroM o �(RE-uSE) �9 N/A 7. THIS PLAN IS FOR PROPOSED SEPTIC SYSTEM ONLY AND IS NOT ' 0 6>> SIDES: \ BOTTOM: 33.25 x 20.5 (.33) = 224.9 TO BE USED FOR ANY OTHER PURPOSE. 8. PIPE FOR SEPTIC SYSTEM TO SCH. 40-4" PVC. GWOODS USE CAUTION IN AREA of G TOTAL: 681.6 S.F. 224.9 GPD 9. COMPONENTS NOT TO BE BACKFILLED OR_CONCEALED WITH❑UT GASUNE USE 3 ROWS OF (5) STANDARD INFILTRATORS EACH, INSPECTI❑IN BY BOARD OF HEALTH AND PERMISSI❑N ❑BTAINED FROM BOARD OF HEALTH. o "WITH 3' STONE AT SIDES AND BETWEEN ROWS, 1' AT ENDS O. DECK /9 �. EXIST. 2 BR O� IN-HOUSE� TM � (SHOP FAMILY) GIFT EXIST. LEGEND TITLE 5 SITE PLAN a WELL PROPOSED SPOT ELEVATION (SEPTIC SYSTEM REPAIR) OF ° �9 100x0 EXISTING SPOT ELEVATION 660 MAIN STREET 100 PROPOSED CONTOUR IN THE TOWN OF: a GRAVEL PARKING (WEST) BARNSTABLE 100 EXISTING CONTOUR 6� PREPARED FOR: M. DAVIS w0 79' Q 30 0 30 60 90 O LOT AREA BOARD OF HEALTH FO C 10 �5 45,000+/- SQ. FT. cF ffj 1.03+/- ACRES O O SCALE Now DATE: APRIL 6, 2001 OAF ,\ry O• APPROVED DATE ��(H OFM,gSS qc\ q � DANIELA•gcy�N ��� DAANIEL ti�� of fV. SEPTEMBER 16, 2021 (ZABEL FILTER) 14 off 508-362-4541 0 O'ALA ss JALA ��y OCTOBER 20, 2021 (BoH COMMENTS) fox 508 362-9880 CIVIL q �No.46502 WIN �� 098 AN.EL s� 4�C/STER� �� OJA ty OJALA down cape engineering, in ASS/ONA E CIVIL " A Np.40985P No.46502 CIVIL ENGINEERS v° °Fess�°` / S'LONA LAND SURVEYORS 939 vain st. yarmouth, ma 02675 0 0-3 6 7 DANIEL A. OJALA, P.E., P.L.S. DATE - __