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HomeMy WebLinkAbout0020 MILL LANE - Health �> 20 Mill Lane W. Barnstable A = 156 .001001', a i t :i No. 4210 1/3 BTU C� Fsnf(giv0aK ESSELTE 10% fl O O O ' No.. .dVJ 1 Fee (l0 ` THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: rt/ PUBLIC HEALTH DIVISION - TOWN OF 9ARN6TABLE, MASSACHUSETTS Yes ZIpplication for Dtgonl *pgtem Con5trurtton Vermtt Application for a Permit to Construct( ) Repair(W,Upgrade( ) Abandon( ) ❑ Complete System U Individual Components Location Address or Lot No. Owner's Name,Address,a,pd Tel.No, Assessor's Map/parcel Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size 73 T sq.ft. Garbage Grinder ( 0 Other Type of Building yp g ems/ e&Ce No.of Persons Showers( ) Cafeteria( ) Other Fixtures -yam Design Flow(min.required gpd Design flow provided �� 7 gpd Plan Date lR 1Z ©,j— Number of sheets f k Revision Date Title e°W g e 5 ,S% AV- d�)7 Size of Septic Tank Type of S.A.S. p Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions 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 o He th. Signed Date Application Approved by Date Application Disapproved by: Date for the following reasons Permit No. Date Issued a3 dJ� evL�� Fee ao 0 »� w_'Q` THE C-O'M►MONWEALTH OF MASSACHUSETTS Entered in computer: Yes ' '„ PUBLIC HEALTH DIVISION - TOWN OF Bi�"�t"g TABLE, MASSACHUSETTS N 2ppricaction for Digo�al �&p.5tem Congtruction Permit Application for a Permit to Construct( ) Repair(►Upgrade( ) Abandon( ) ❑ Complete System v Individual Components Location Address or Lot No. Owner's Name,Address,and Tel.No.- Assessor's Map/Parcel Installer's Name,Address,and Tel.No, 7 7� 7-1T/ Designer's Name,Address and Tel No. Type of Building: �-7 Dwelling No.of Bedrooms Lot Size /✓� sq.ft., Garbage Grinder Other Type of Building /��dJl' No.of Persons r Showers( ) Cafeteria(i ) Other Fixtures +te it 'r 'f Design Flow(min.required) gpd Design flow provided / `� gpd Plan Date 1,r/Z/le .J Number of sheets / Revision Date Title 5E'ltlG?Rei, 5 y57eW �5%4` 0/ )0'jW/'41Jk1w Size of Septic Tank //}/%p Z ,ISM Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement:' The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions 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 off Health. 1 Signed r< ✓" Date Application Approved by Date Application Iisapproved by: Date — for the following reasons A Permit No. 2t,,,,f'—t.,V Date Issued I ,23 oj "———————————— ——— ——————————— �\ dJ THE COMMONWEALTH OF MASSACHUSETTS t Q BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disis sal System Constructed ( ) Repaired ( p< Upgraded ( ) Abandoned( )by kf �?ZJ/i / at Gy� �/�1 �''�� L./�i /0/0-914 1e has been constructed in accordance `I with the provisions of Title 5 and the for1Disposal System Construction Permit No. )W � dated Installer ed t0 "i DesignerAL1 #bedrooms -if ,Approved design flow gpd The issuance of this peii5M i. s be construed as a guarantee that`the system ilvlll fu-nct n as de igned. Date 1 Inspector ———————————————————————————————————————————— No. )r 7 3 — - Fee U d THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS lwigozal *p.5tem Construction Permit Permission is hereby granted to Construct ( ) Repair ( t/j Upgrade ( ) Abandon System located at 7_O �l/�C' ` /� �rs�s and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title S and the following local provisions or special conditions. Provided: Construction must be completed within three years of the date of this(pe mi . 12 Date 0 1-)3 >��S Approved by u "�- 9 �/ No.W. J0 � - Fee----- ---- ------ BOARD OF HEALTH TOWN - OF BARNSTABLE Zipplicat ion fforVell, Construct ion Permit Application is hereby made for a permit to Construct , Alter ( ), or Repair ( )an individual Well at: Location — Address Assessors Map and Parcel Owner Address Installer — Driller Address Type of Building Dwelling Other - Type of Building—=--- ------ No. of Persons— —_ Type of Well— U L---- — Capacity—&--- ——1----- Purpose of Well---( fA,A ON 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 Mcertificate .of Compliance has been issued by the Board of Health. �r A o� Signe d —_— Application Approved By ® —— C/�--- date Application Disapproved for the following rea s ----------------------------------------- • ® date Permit No. —= — Issued-- . .; .. — - ----------- ------- a. ate BOARD OF HEALTH TOWN OF BARNSTABLE (Certificate ®f Compliance THIS TO CERTIFY, That the Individual Well Constructed (16ltered ( ), or Repaired ( ) by—_ h4 of O --- LAJ Fe -------- 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. ----------Dated----- --- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE---- - -- Inspector-- --__- -----—---------- No.---Wk- - - Fee------ ------------- BOARD OF HEALTH I / TOWN- OF BARNSTABLE . Application-for Vell Con5truct ion Permit Application is hereby made for a permit to Construct (-*I, Alter ( ), or Repair ( )an individual Well at: Location — Address Assessors Map and Parcel Owner Address Installer — Driller Address Type of Building t J Dwelling Other - Type of Building - No. of Persons-\_\ - -----=-_ ----------- YP n ------------- T e of Well si P V L Ca acit �U ---- YP P Y------ Purpose of Well-- U-- �_ 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 ertificate of Compliance has been issued by the Board of Health. Si ne g m � � J�SI Application Approved BY v _ date � Application Disapproved for the following rea s -------- ----- -- 3 _ / date Permit No. — Issued-- � (�—•------------- kate . r BOARD OF HEALTH TOWN OF BARNSTABLE C ertlf icate ®f (Compliance THIS TO CERTIFY, That the Individual Well Con ructed (Altered ( _ ), or Repaired ( ) Installer t at— ) I L( _ has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation as described in the application for Well Construction Permit No. ----- -----Dated----- ----- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE--- -- Inspector--_--_-----__-_�_ __ _—_---_-_-- BOARD OF HEALTH TOWN OF BARNSTABLE Seri con5truct ion Permit No' -V- - Fee- Permissio�is'_,Nby grantedp to Construct ); terO or Re airy No Street as shovjTj on the applic✓i fora Well Construction Permit No.- — - Dated- v - r ----------------------- ------------------------ Board of Health DATE � w y • w C4 ate x /4 44 IL rA lick 1: yb"�v 1 � � ell �VBw _ N 74 l-l.1/w J'Tk ED 4E of P.�vEMEn►7' / . i oll ti ,... ti t r • ..46 N9x 7 Sx No.TES a/ f;ri Soy s ' 1 EX IST NG C ON- 10, 4 i 34 p r�IV WAY s...e l , _ 1 TOWN OF BARNSTABLE LOCATION ,tea ///� Z'V SEWAGE VILLAGE a tea`-A,,olWe ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. 3rx�/ OF-79je SEPTIC TANK CAPACITY /,aew GcL LEACHING FACILITY: (type) 00G1164ey, —J ��� (size) /3,e7Y.tIca, NO. OF BEDROOMS y BUILDER OP�Cf�✓N / �ra,��I,,b, PERMIT DATE:��7y dJ' COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facih ) Feet Furnished by D tsrt-1 e - r � 1 \vo 175 O I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 20 Mill Lane Property Address Janet Benjimanson Owner Owner's Name information is required for Barnstable MA 02630 09/21/09 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. ImpoWhen filling A. General Information When filling out forms on the t computer,use 1. Inspector: only the tab key p to move your Michael Kellett cursor-do not Name of Inspector use the return key. Aardvark Environmental Inspection Company Name ffi P.O. Box 896 Company Address East Dennis MA 02641 Cityrrown State C 7 Zip Code w 508-385-7608 S13742 Q Telephone Number License Number t ` f -T1 B. Certification I certify that I have personally inspected the sewage disposal system at this addr s and that the information reported below is true, accurate and complete as of the time of the insrpection. ge inaction 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 _�r G l�t� 09/25/09 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. USGS•12/07 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments t 20 Mill Lane Property Address Janet Benjimanson . Owner Owner's Name information is required for Barnstable MA 02630 09/21/09 every page. CitylTown State Zip Code Date of Inspection B. Certification cont. Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The covers on both tank and pit were at one foot. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y, N, ND) in the ❑ for the following statements. If"not determined," please explain. ❑ The septic tank is metal and over 20 years old* or the septic tank(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. 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 USGS•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 Commonwealth of Massachusetts uTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 20 Mill Lane Property Address Janet Benjimanson Owner Owner's Name information is required for Barnstable MA 02630 09/21/09 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ obstruction is removed ND Explain: 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 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. USGS•12/07 Title 5 Official Inspection Fomr.Subsurface Sewage Disposal System•Page 3 of 15 Commonwealth of Massachusetts lugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 20 Mill Lane Property Address Janet Benjimanson Owner Owner's Name information is required for Barnstable MA 02630 09/21/09 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: *"This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® 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 '/z day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. USGS•1?J07 Title 5 Official Inspection forth:Subsurface Sewage Disposal System•Page 4 of 15 f - Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 20 Mill Lane Property Address Janet Benjimanson Owner Owner's Name information is required for Barnstable MA 02630 09/21/09 every page. Citylrown State Zip Code Date of Inspection B. Certification (cunt.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® 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 facility with a design flow f 2 00 ❑ y p g a y g o 0 gpd- 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. USGS•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments •�� 20 Mill Lane Property Address Janet Benjimanson Owner Owner's Name information is required for Barnstable MA 02630 09/21/09 every 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? El ® 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)] USGS•12107 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 20 Mill Lane Property Address Janet Benjimanson Owner Owner's Name . information is required for Barnstable MA 02630 09/21/09 every page. Citylrown State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms(design): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No la undry aund on a separate sewage system? if es se crate'ins inspection required] Yes N rY Po 9I Y P p q ,l ❑ Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage(gpd)): Sump pump? ❑ Yes ® No Last date of occupancy: current 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: Last date of occupancy/use: Date Other(describe): USGS-12/07 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 7 of 15 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M b 0y`'s 20 Mill Lane Property Address Janet Benjimanson Owner Owner's Name information is required for Barnstable MA 02630 09/21/09 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank,distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: 12/23/05 per BOH Were sewage odors detected when arriving at the site? ❑ Yes ® No USGS-12107 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 20 Mill Lane Property Address Janet Benjimanson Owner Owner's Name information is required for Barnstable MA 02630 09/21/09 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) -Building Sewer(locate on site plan): Depth below grade: 2.0 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: 1.2 feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No --------------------------------------------------------------------------------------------------------------------------1000 gal Dimensions: , Sludge depth: 3" Distance from top of sludge to bottom of outlet tee or baffle 29" Scum thickness 2" n Distance from top of scum to top of outlet tee or baffle 7" Distance from bottom of scum to bottom of outlet tee or baffle 16" How were dimensions determined? measured USGS•12107 Title 5 Dual Inspection Form:Subsurface Sewage Disposal System-Page 9 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M , 20 Mill Lane Property Address Janet Benjimanson Owner Owner's Name information is required for Barnstable MA 02630 09/21/09 every page. City(rown 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.): The tank was sound and tight with tees in place and liquid at outlet invert. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): USGS•12/07 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 10 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 20 Mill Lane Property Address Janet Benjimanson Owner Owners Name information is required for Barnstable MA 02630 09/21/09 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank(cont.) 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 Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert even Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): The box was level and tight with no sign of carryover. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No USGS•12107 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 20 Mill Lane Property Address Janet Benjimanson Owner Owners Name information is required for Barnstable MA 02630 09/21/09 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System(SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ® leaching chambers number: 3 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): The system has three five hundred gallon drywells in a thirteen foot bythirty-four foot stone field. There was no sign of ponding or failure in the stones. USGS•12107 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �M 20 Mill Lane Property Address Janet Benjimanson Owner Owner's Name information is required for Barnstable MA 02630 09/21/09 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No 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.): USGS•12107 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 20 Mill Lane Property Address Janet Benjimanson Owner Owner's Name requir adon a required for Barnstable MA 02630 09/21/09 every page. Citylrown State Zip Code Date of Inspection D. System information (corn.) Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. i '75 Ifo� a3 USW•1 ZIW Title 5 ORW hWeam Forth:SUmdow Smgp rksprrsal System•Page 14 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 20 Mill Lane Property Address Janet Benjimanson Owner Owner's Name information is required for Barnstable MA 02630 09/21/09 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ❑ Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: 20.0 feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: You must describe how you established the high ground water elevation: USGS maps show an elevation of over twenty feet. USGS•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 15 Page: CERTIFICATE OF ANALYSIS ' Barnstable County Health Laboratory �`.A.C13135. Report Dated: 6/21/2006 Report Prepared For: Order No.: G0635654 Leon Malkin c/o Dorothy Sherin 180 Beacon Street,Apt.2E Boston, MA 02116 Laboratory ID 4: 0635654-01 Description: Water-Drinking Water l Sample : Sampling Location f 20-Mi ff Ln;W.Barnstable,MA Collected: 6/1/2006 Collected by: Skip Gibson Map 156 Parcel 001-001 Received: 6/2/2006 Routine ITEM RESULT UNITS RL MCL Method# Analyst Tested Note LAB: Inorganics Nitrate as Nitrogen 1.7 mg/L 0.10 10 EPA 300.0 LAP 6/2/2006 LAB: Metals Copper 0.21 mg/L 0.10 1.3 SM 3111B LAP 6/6/2006 Iron BRL mg/L 0.10 0.3 SM 3111B LAP 6/6/2006 Sodium 20 mg/L 1.0 20 SM 3111B LAP 6/6/2006 LAB: Microbiology Total Coliform Absent CFU/IOOmL 0 Absent SM 9223 B AF 6/2/2006 LAB: Physical Chemistry Conductance 400 umohs/cm 2.0 EPA 120.1 DCB 6/l/2006 pH 7.8 pH-units 0 EPA 150.1 DCB 6/1/2006 I Lodium,level is at the maximum contaminant level-Those-on-a-low sodidth" iet may wishao onsult ptiysici n Approved By: (Lab rector,) c.._ i/ �g M RL = Reporting Limit MCL=Maximum Contaminant Level Superior Court House, PO.Box 427, Barnstable, MA 02630 Ph: 508-375-6605 l i ._. Town of Barnstable J y�P, °Ft,-mow Regulatory Services _ _.... .. Thomas F.Geiler,Director l � 00t —COO • BARNSTABLE. • <4 "6 Public Health Division Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office:.508-862-4644 Fax: 508-790-6304 Installer & Designer Certification Form Date: Designer: DA y/,CJ Installer: �- 2�l/ Address: . Address: _ n�.��,,, "V On Z an7 OS' j /m�,�1' )tu��o�• was issued a permit to'install a (date) Al (installer) septic system at zo l dl !4h e . 1/V. &OVAs, based on a design drawn by J (address)� dated u vs \l (designer) /"� 1 certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system)but in accordance with State& Local Re ations. Plan revision or ;cerZfifieL,dl _bUi11tby designer to follow. ®�lyk OF AIAG, ARREN . o staller's Signature) o. 114G a �FGISTEaF. D 0� (Designer's Signature) (Affix Designer's Stamp Here) PLEASE RETURN TO B STABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q:Health/Septic/Designer Certification Form SENT BY: BORTOLOTTI CONST; 5084289399; DEC-23-05 9:29; PAGE 2/2 Oac, 23 .,05 10: 27a I ; P, 1. Notice: This Norm Is To Be Used For the Repair Of Oailed Septic Systems Only PERCOLATION '17EST AND SOIL EVALUA'110N EXE PTIQN FORM i ereby certify that tho engineered plan sj rn d by me i ;r dated_ ,conccming the property located at + U ��• l._Z- LA r'1 meets all of the following criteria: z • Two soil evaluations oxcav,►tcd for detailed examination(Ito hand au Bring) nd two percolation tests shill be conducted, I fi; • This fallod eystem is connected to a residential dwelling only. Thery arc no 4mincreial or business uses awociatcd with the dwelling. i • The coil it classified as CLASS I and the percolation rate is less than r equal)to 5 minutes ' per inch. I • There is no incrouse in flow and/or change in use proposed j • Thcrc arc nu variances rcqucsted or needed. T • 'I'hc bottom of the proposetl leaching facility will be located no less than live LtabovC the maximum adjusted groundwater table elevation. [Adjust the groundwater tabl�-using the Frimptor method when applicable] Ple:Isc complete the following: I A) Top of Ground Surface Elevation(using ULS inforntation) t 13 G.W. Elevation �- ad'u'ttnent for high G.W. 't J g C)lFk'l:RENCE 131 TWEVN A and A TEM s SIGNFD : ✓ 1 DATE;- Z- L_ 3 I i NOTICE ; Based upon the above information, a repair pun-nit will be issued for_— bedr outs maximum. No additional bedrooms are,tuuhorizcd in the future without c tgincerid septic systern puns. f, qA�cpucAperseaemp_duc ! i r• i - EN1IIZ07I'C:HI.AI30RA7'ORIIs.S,INC..:: A1A (ER7: NO.:tt1-AlA 063 449 Ric. MO Sand►►ich, XIA 0256.; .508(888-64/,l/) 1-800-3.39-6460 �°�"` � I A.Y(508)888-6446 JAN 14 2003 TOWN OF BARNSTABLE HEALTH DEPT. CLIENT: Robert Benjaminson LOCATION: 20 Mill Lane ADDRESS: 20 Mill Lane W. Barnstable, MA 02668 W. Barnstable, MA 02668 COLLECTED BY: Desmond Well Drilling SAMPLE DATE: 12/23/2002 SAMPLE TIME: 2:OOPM WATER SAMPLE TYPE: New Well DATE RECEIVED: 12/24/2002 LAB I.D. #: 0212337 WELL SPECS.: 4"/207 55' RESULTS OF ANALYSIS: Parameters Units Recommended Results Method Date Analyzed Limits Coliform bacteria /100ml 0 0 9222 B 12/24/2002 PH pH units 6.5-8.5 6.84 4500 H+ 12/24/2002 Conductance umhos/cm 500 165 120.1 12/24/2002 Nitrate-N mg/L 10: 2.48 300.0 12/24/2002 ti Nitrite-N mg/L 1.00-:. _ < 0.004 300.0 12/24/2002 Sodium mg/L '; ,20.0 .�. . ' '18.3 ._o;*.=...__.... .._ 200.Z 12/27/2002 Iron mg/L 0.3!. _ < 0.1 2001 ' 12/27/2002 Manganese mg/L 6.05` < 0.008 200.7 12/27/2002 Volatile Organics ug/L See Report None Detected. EPA 524.2 12/31/2002 WATER MEETS EPA STANDARDS AND/S SUITABLE FOR DRINKING PURPOSES FOR PARAMETERS TESTED. i ND= None Detected. <=less than >=greater than TNTC=too numerous to count Date :. onald J. Saa / atoitfoL borry r.. I . , F Jan=071-03i 12 : 13P L a p u c k Laboratories , Inca 781 401 9998 P .02 CERTIFICATE OF ANALYSIS Oage- LAPUCK LABORATORIES, INC. Report Prcnarcd For: Report Daled: 01/07/2003 Fnvirotech Laboratories,Inc. Order Number: L0273759 Ron Saari 449 Rte, 130 Sandwich, Ma 02563 Laboratory iD#: 0273759-01 Deccrintion: 0212337 Sample N: Samnllny Location: Collected: Collected by: Customer Received: 1 2126/2 0 0 2 EPA 524.2- Volatile Organics by GURS ITEM RESOLT UNITS MDL Method# 'Tested LAB: Organics 1,1,1,2-Tetrachlorocthane ND ug/L 0.5 ern 524.2 12/31/2002 1,1,1-Trichloruethane ND ug/L 0.5 FPA 524.2 12/31u2002 1,1,2,2-Tetrachloroethane ND 1)8/1. 0.5 EPA 524.2 12/31,12002 1,1,2-Trichluroethane ND ug/L 0.5 Lrn 524.2 12/3 1!20n2 1,1-Dichlorethane ND ug/l. 0.5 FPA 524.2 12/31;2002 1,1-Dichluruethene ND ug/L 0.5 EPA 524.2 12/31/2002 1,1-Dichloroprupene ND ug/L 0.5 HFA 524.2 12/312002 1,2,3-Trichlorobenzene ND 118/1. 0.5 EPA 524.2 12/31/2002 1,2,3-Trichloropropauc ND ug/L 0.5 Ern 524.2 12/31;2002 1,2,44'richlorobcnzcne ND ug/1. 0.5 EPA 524.2 12/31;2002 1,24-Trimcthylbenzene ND ug/L 0.5 EPA 524.2 12/31/2002 1,2-Dibrumo-3-Chloroprupa ND ug/l. 0.5 LTA 524.2 12/31/2002 112-Dibromoethane( DB) ND ng/L. 0.5 EPA 524.2 12/31/2002 1,2-Dichlorubenzene ND ug/L. 0.5 EPA 524.2 12/31/2002 1,2-1)ichloroethane ND ug/L 015 EPA 524.2 12/31/2002 1,2-Dichloro props ne NY) ug/L 0.5 Lrn 524.2 12/-W2002 1,3,5-Tr1methy1bcnzene ND ug/L 0.5 FPA 524.2 12/3U2002 1,3-Dichluruhenzene ND ug/L 015 EPA 524.2 12/31i2002 1,3-Dichlorupropane ND US/I. 0.5 EPA 524.2 12/310002 1,4-Dichlurubenzene NI) ug/L 0.5 EPA 524.2 12/.31/2002 2,2-Dichlorupropane ND ug/L 0.5 FPA 524.2 12/31/2002 2-Chlorotoluene ND ug/L 0.5 EPA 524.2 12/31/2002, 4-Chlorotoluene ND ug/L 0.5 EPA 524.2 12/31/2002 4-lsopropyltoluene ND ug/L 0.5 EPA 524.2 12/31i20o2 Jan-07-03 i. 12 : 14P Lapuck Laboratories , Inc . 781 401 9998 P . 03 CERTIFICATE OF ANALYSIS P`1K` 2 LAPUCK LABORATORIES, INC. Report Prepared For: Report Dated: 01/07/2003 Envirotech Laboratories,Inc. order Number: L0273759 Ron Saari 449 Rte. 130 Sandwich, Ma 02563 Laboratory ID#: 0273759-01 rignerintiun; 0212337 Sample 11: Samnll,nt Imentivil: Collected: Collected by: t'uslurner Received: 12/26/2002 Benzene ND Ugil. 0.5 LiPA 524.2 I2/31/2002 Bromobenzene ND ug/L 0.5 EPA 524.2 12/31/2002 Bromocbloromethane 'ND ug/l. 0.5 EPA 524.2 12/31/2002 Bromodichloroethane ND ug/L 0.5 EPA 524,2 12/31/2002 Bromofor><n ND ug/L 0.5 F:PA 524.2 12/31/2002 Brnmomethanc ND ug/L 0.5 EPA 524.2 12/311;2002 ! CarbonTetrachlorlde ND ug/L 0.5 urn 524.2 12/31:'2002 i Chlorobenzene ND ug/L 11.5 EPA 524.2 12/31R1102 Chloroethanc ND ug/L 0.5 IiPA 524.2 12/31/2002 ! Chloroform ND ug/L 0.5 EPA 524.2 12/31/2002 ! Chloromethane ND ug/l. 0.5 F.PA 524.2 - 12/31/2002 cis-1,2-01chlorethenc ND pg11, 0.5 EPA 524.2 12/31/2002 cis-1,3-Dichloropropene ND ug/L 0.5 EPA 524 12/31/2002 Dibromochloromethane ND ugn, 0.5 EPA 524.2 12/31/2002 l Dibromomethanc ND ug/L 0.3 EPA 524.2 12/31/2002 } Dichlurodifluoromcthane ND ug/L 0.5 EPA 524.2 12/31/2002 Elhylbcnzene ND ug/l. 0.5 FPA524.2 12131tz002 ilcxachlorobetadicne ND ug/L 0.5 CPA 524.2 12/31/2002 I,t lsupropylbenzcne NJ) ugn, 0.5 EPA 524.2 12/31/20o2 i MethyleneChloridc ND ug/l. 0.5 FPA 524.2 12/3112002 n-Butylhenzene ND r• .ug/L 0.5 EPA 524.2 12/31/2002 n-Pro (benzene ND r` . ug/L 0.5 LPn sz4.2 12/31/2002 � PY . Naphthalene ND ug/L 0.5 CPA 524.2 12/3112002 sec-Butylhenzene ND ug/L 0.5 EPA 524.2 12/31'201)2 Styrene N1) ug/L 0.5 CPA 524.2 12/31/2(107. tort-Butylbenzenc ND jig/I. 0.5 EPA $24.2 12/31/2002 Tctrachloroethenc ND ug/l. 0.5 EPA 524.2 12 2. /31/200 ug/L 0.5 EPA 524.2 12/31/2002 Toluene Nl) r Jan-07-03 12 : 14P Lapuck Laboratories , Inc . 781 401 9998 P . 04 1'ag e: 3 CERTIFICATE OF ANALYSIS LAPUCK LABORATORIES, INC. RCDort Prepared Nor; Report Dated: 01/07/2003 Envirotech Laboratories,Inc. Order Number: L0273759 Ron Saari 449 Rtc.. 130 Sandwich, Ma 02563 Laboratory ID#: 0273759-01 Description; 0212331 Sample N: lam Location: Collected; Collected by: Customer Received: 12126I2002 trans-1,2-Dlchloroet.hene NJ) ug/L 0.5 FPA 524.2 12/31/2002 trans-1,3-Dichloropropene ND ug/L 0.5 LPA 524.2 12/31/2002 Trichluroethene ND ug/L 0.5 FTA 524.2 12/31/2002 Trichlorofluu rolnCthane ND ug/L 0.5 EPA 524.2 12/31/2002 VinylChloride ND ug/L 0.5 CPA 524.2 12/3 V2002 �i i Xylene ND ttg/l. 0.5 EPA 524.2 12/31/2002 Approved By:. (lab Manager) 'Phis rci)nrt is rendered upon the condition that it is nut to be reproduced wholly or in part for advertising ur ulhcr purposes over our signature or in eonneehon w/ i uur^name without special written permission.'final liability is limited to the invuiued amonnt.The results listed refer only to tested samples acid/or applicable I I tf i I. �I 'i t Massachusetts Department of Environmental Management 118444 Office of Water Resources TYPE OR PRINT.ONLY Well Completion Report .WELL LOCATION GPS (OPTIONAL) LATITUDE LONGITUDE Address at Well Location: Property Owner: TK -ter' Subdivision Name: Mailing Address: aO I'� I �ln� •--. CityfTown: City/Town: r' -boy Assessors Map Assessors Lot#: 0(� NOTE: Assessors Map and Lot# mandatory if nostreet�Tad�`dress available Board of Health permit obtained: Yes_IX Not Required El Permit Number 1W12002-"73 Datelssued` f a ZI4,10Q 2. WORK PERFORMED 3. PROPOSED USE 4.'DRILLING METHOD New Well ❑ Abandon C4 Domestic ❑ Irrigation ❑ Cable ;Auger 8 ❑ Deepen ❑ Recondition El Monitoring ❑ Municipal ❑ Air Hammer Direct Push ❑ Replace ❑ Other ❑ Industrial ❑ Other ❑ Mud1h8tarV0 ,0 Other 5. WELL LOG oC Unconsolidated Consolidated 6. SITE.SKETCH(use peRmanim landmarks with diatan�s) � W Permeability , Q - RECE' _ 0 Other Rock Type From (ft) To (ft) High Low c7 mI 0 - - ►o - 58 F-M JAN 0 7 2003 '11 TOWN OF BA- HEALTH u'...P l ( "t �d ESL SBA G3 } #20 Mt Lt_ L-At4 S 7.WELL CONSTRUCTION & CASING Total Depth Drilled - SS From (ft) To (ft) Casing Type and Material Size O.D. (in) Well Seal Type Date Drilling Complete 1- 8t' - Sl ft - t'o PvG �ti 9. SCREEN ' From (ft) To (ft) Slot Size Screen-Type and Material Screen Diameter 5 T ,,r�-tt 10. FILTER PACK/GROUT!ABANDONMENT MATERIAL s£ f 11:ADDITIONAL WELL INFORMATION--- Developed? Yes ❑ No From (ft) To (ft) Material Description` Purpose - Fracture Enhancement? ❑ Yes ['$'No Method / , \ ) Disinfected? Yes ❑ No 12. WELL TEST DATA(PRODUCTION WELLS) = 13;PSTATICVATERILEVEL(ALL WELLS) Yield-.`NTirrie Pumped Drawdown to Time Recovery to Depth Below Date Method (GPM), 'w(Firs'&min) (Ft. BGS) (hrs & min) (Ft. BGS) Date Measured Ground Surface (FT) taloJgq�pvn„p �b`�" .F,r•5� a � tMMr=D �L� 1a �3 oa - av 14. PERMANENT PUMP (IF AVAILABLE) _ t5.,AMEIADD,RkSS OF Pt►lr<[P"INSTALWON COMPANY �oCt�S` ,l007' Horse,ower 3 %� P De ump scnption p Pum Intake De th p (ft) Nominal,F'ump'CapacityG (gPm). �c: 7 dr-lr 16. COMMENTS •� g 17.WELL DRILLER'S STATEMENT This-well was deilled`and/or ab ndoned'un r my supervision;according to applicable rule's and regulations, and this rep , is comp) (e nd orrect to the best of my knowledge. Driller:��+nrrirnf�1 � �� t) Supervising Driller Signature: Registration #:I 171 A Firm: r < (i �� Date: ) -''4 "�� - Rig Permit#: � NOTE. Well Completion Reports must be fled by the registered well driller within 30 days of well completion. BOARD OF HEALTH COPY C)d � Commonweatth-of Massachusetts Executive Office of -Environmental Affairs - John Grad - D.E.P. Title.V-Septic Inspector Department of _ - _ P.O.-Box 2119 Environmental Protection Teaticket,.M-A 02536. - (508) 564-6813 - Wllllam F.Weld. _- Trudy t;oxe - 8eereLai ,EOEA _ David B.Struhs —— commiuioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM � - --PART A _ CERTIFICATION - ✓U { � r i Property Address: O 01\\\ ��- '�ak �S `b�i4ddress of Owner: N 2 Date of Inspection: �`ai�� t (� (If different) 199,5 Name of Inspector: Company Name, Address and Telephone Number: - 14 / g C CERTIFICATION STATEMENT I certiF, that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: t-`P"a`sses — Conditionally Passes _ Needs Further Ev Iuation By the Local Approving Authority _ Fails 1 Inspector's Signature: Date: 1 lol Q� The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this inspection. If the system is a shared system or has a design flo�N of i0,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent t,� :ne system owner and (ope- sent to thle uu)er, if applicable and the appro,inb author t�. INSPECTION SUMMARY: Che k A B, C, or D: A] SYSTEM PASSES:� V I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B] SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes inspection. Indicate yes, no, or not determined (Y, N, or Ill Describe basis of determination in all instances. If"not determined", explain why not) The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 8/15/95) 1 One Wither Street a Boston,Massachusetts 02108 a FAX(617)SWI049 a Telephone(617)292-SM Printed on Recycled Paper } 71 , SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION-FORM PART A CERTIFICATION (continued) - Property Address: Owner: - Date of Inspection: — -- B] SYSTEM CONDITIONALLY PASSES (continued) _ Sewage backup or breakout or high static water Iev4 observed in.the distribution box is due to broken or obstructed _ pipe(s) or due to a broken,settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Hearth): - - broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced - _ The system required pumping more than four times a year due to broken or obstructed pipe(s)-. The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed 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 the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A.MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRON iE\T: '_ . _ InP >k Steni na> a >ewi( tank af)u �Uu db�OfpUon Cni of rid Li Kiihn� ivv icci to a iuna_�c a��, i..h'N � ... .�� surface water supply. _ The scorn- ha, a septic tank and soil absorption system and is within a Zone I of a public water supply well.. _ The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. _ The ;-,stem has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis 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• D] SYSTEM FAILS: v n r f h following failure criteria as defined in 310 CMR 15.303. The basis I have determined that the system violates one or more o the o g for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. _ Backup of sewage.into facility or system component due to an 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. (revised 8/15/95) 2 s SUBSURFACE SEWAGEDISPOSAL SYSTEM INSPECTION FORM - PART A CERTIFICATION (continued) Property Address: - Owner: - - Date of Inspection-AA �( _ D] SYSTEM FAILS (continued): 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. - 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 Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a 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 I of a public well. I 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. El LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above: The design floe, of system is 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply _ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area (IWPA) or a mapped Zone II of a public water supply well, The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 8/15/95) 3 - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM --PART-0 CHECKLIST Property Address: oc", - Owner: ��i(lZ•\\G - Date of Inspection: - Check if the following have been done: _,,plumping information was requested of the owner, occupant, and Board of Health. _L,1d'6ne of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. Abuilt plans have been obtained and examined. Note if they are not available with N/A. fie facility or dwelling was inspected for signs of sewage back-up. L,We system does not receive non-sanitary or industrial waste flow the site was inspected for signs of breakout. c—AlTsystem components, excluding the Soil Absorption System, have been located on the site. L-IT e septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. L-fhe size and location of the Soil Absorption System on the site has been determined based on existing information or approximated bv non-intrusive methods. TV e {a".''.'.'.' ii difforp- frnm 0�%ne-� were provided with information on the proper maintenance of Sub- Surface Disposal System. (revised 8/15/95) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - - PART C - - SYSTEM INFORMATION - -- Property dress: _- Owner: Date of InspeZtiBrt:'Z\\\O. - �, FLOW CONDITIONS RESIDENTIAL Design flow: allons Number of Number-of current residents: Garbage grinder (yes or no):�L - - Laundry connected to-system (yes or no)k=A.—r5 Seasonal use (yes or no):'-4 � Water meter readings, if availabTe: Last date of occupancy: COMMERCIAUINDUSTRIAL.0\ Type of establishment: Design flow: gallons/day 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 occupancy: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RRTRDS and source of information:-a a ,�� 1 C1 System pumped as pan of inspection: (ves or nokirS If yes, volume p ^sped l 0J gallon Reason for pumping: TYPE OF STEM 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) Other (explain) APPROXIMATE AGE of all components, date installed (if known) and source of information: Sewage odors detected when arriving at the site: (yes or no)� (revised 8/15/95) 5 9 - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM s. PART C SYSTEM`INFORMATION (continued) _ Property dress: "� Owner: Cf,c 1 \� Date of Inspection SEPTIC TANK: - (locate on-site plan) — - Depth below grader Material of construction: _concrete _metal_FRP_other(explain) _ Dimensions: - \\ Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle:C�9I Scum thickness: LAINt1 Distance from top of scum to top of outlet tee or baffle.___,_ y�\ Distance from bottom of scum to bottom of outlet tee or baffle:_ Comments: (recommendation for pumping, conditionQk inlet and outlet tees or baffl s, depth of liquid level in relation to outlet invert, structural integrity, evidence kage, etc.) , V Ql J GREASE TRAP:�� (locate on site plan) Depth below grade: Material of construction: _concrete _metal _FRP —other(explain) Dimensions: Scum ihici ne��. Distance from top of scum to top of outlet tee or baffle: Dictanrn frog^ bottom of cri— to hortom of outlet tee or baffle: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.i (revised 8/15/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART C. - SYSTEM INFORMATION (continued) Property ress: �. _- Owner: LCat12.\fig - Date of Inspection: TIGHT OR HOLDING TANKQ (locate on site plan) Depth below-grade: Material of construction: _concrete_metal _FRP _other(explain) - Dimensions: Capacity: gallons Design flow: gallons/day Alarm level: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: (locate on site plan` Depth of liquid level above outlet invert: Comments: (note if level and di.�tnbutiuo a eyudi, e�iUcilcc.of solidi ca:r)c,er, e�idence of leakage into or out of box, ex. PUMP CHAMBER: (locate on site plan) Pumps in working order.(yes or no) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (revised 8/15/95) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM _. PART SYSTEM INFORMATION (continued) Property Address: Owner: SCfl �\\p — Date of Inspection: SOIL ABSORPTION SYSTEM (SAS): / (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type ls2G� �l�- - leaching pits, number. 03C\gym leaching chambers, number._ leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Comments: (note con ition,4f soil, signs of h draulic failure, lev�e�of Londing, condition of vegewi�etc.) 1 (�.�Lt�-(1 PiA- CESSPOOLS:�� (locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool materials of construction: Indication of ground.•.a:c- inflow (cesspool must be pumped as part of inspection) 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.) (revised 8/15/95) 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION. (continued) - Property Address: <DV - __ Owner:. S --\2 `v(3 _ -Date of Inspec io � - SKETCH OF SEWAGE DISPOSAL.SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' - - - lo C� (o4�u e G i ® � AA R �3 �c DEPTH TO GROUNDWATER Depth to groundwater: 1 C)- feet method of determination or approximation: erC f tS (revised 8/15/95) 9 r _ ASSESSOR'S MAP NO. 5 PARCEL L0L-ATION SEW AGEE PERMIT NO. 113 av111ov. St - , west Bar,, 85-905 VI Ft AG E �,o0o � � n� rA'�'' A `Zo ILL LA West Barnstable I N S T A LLER'S NAME i CA Sid'S TR.UCKING INC . Rix 7 _ Yarn.outhPort , %rla.. 02675 8 U1,LDER OR OWNER Isabelle Kelley 113 Willow Street, viest 'Barnstable, 11a. 02668 GATE PERMIT ISSUED 9/4/�36 DATE COMPLIANCE ISSUED 9/10/86 s r ' Q TEST PIT PERC. TEST - EXISTING ,I� --�� �- GRAD ` O" - 99.5 SANDY LOAM O" - 98.75 )' r 18 - A 98.0 1 OYR 3/2 19,, A " 97.17 SANDY LOAM B I OYR,G/8 B 95.0 5' REMOVAL TO 42" - 9G.0 45" r " - M" ( •a'It EL. 5G.08 OR TOP SILT LOAM OF C2 LAYER C I 2.54 7/3(10 YR,5/5) Cl LOCUS MAP 150.0' 150" - 87.0 152 - 8G.08 P P I 5GO°04'37"E E DESIGN I394-50 E S (� m h 99_ j C C SINGLE FAMILY DWELLING W/4 BEDROOMS •, �a0 � Al N 15 6'-0 I "0 I C2 85.5 MEDI2.UM M4AND C2 -85.5 NO GARBAGE DISPOSAL N4 �\ I SEPTIC TANK(VO DAILY FLOW= B L.READ) I Ogpd/BR = 440 G.P.D. �2 Qo'oQ„w (LOT 1 ) 440 G.P.D.X 200% = 8,50 GALS 4•°Q, 74,734±5F I,000 GAL.TANK-O.K. (EXISTING) � Tti-2 y / 150.0 63.0 204 - - 81.75 o ) NO GW OBSERVED NO GW OBSERVED LEACHING AREA(5.A.5.)-USE(3) 500 P.C. Leach Chaimbers w/4'stone on all sides ri '�04 � 33.5' X 13'W X 2'D P.C. CONC. L.C. STONE No. 20 TESTED I O/G/2005 SIDEWAH = [(33.5)2 + (13)2]X 2 X 0.74 = 137.G4 S 1 112 STY. 00 S, /Wo. FR. LQSoil Evaluator: DMeyer Me O T.O.F. = 103.G8 0 BOTTOM = 33.5 X 13 X 0.74 = 322.27 °o, ! CLASS I SOILS IN C2 LAYER -B -- \ LTAR = 0.74 gpd/ft 2 TOTAL CAPACITY= 459.9 GALS. EXISTNG / h > 440 Gal/Day recfd OK o � / � o \ I ,000 GAL. ` 2 o CO NOTES: SEPTIC TANKo 5 40 13'00'W MILL LANE LEACN I LEACH PIT (NOTE 7) O -.�( _I -THE--INSTALLATION IVUS_T-BE IN SUBSTANTIAL COMPLIANCE WITH THIS PLAN, --,J 1995 MASSACHUSETTS TITLE V *TOWN OF BARNSTABLE BOARD OF HEALTH REGULATIONS 2. THE INSTALLER SHALL VERIFY THE LOCATION OF UTILITIES, SEWER INVERTS GRAPHIC SCALE AND SEPTIC COMPONENTS PRIOR TO INSTALLATION. 3. THIS PLAN SHALL BE USED FOR SEPTIC SYSTEM INSTALLATION ONLY, AND 40' 0' 20' 40' 80, O, SHALL NOT BE USED FOR PROPERTY LINE DETERMINATION 4. ALL PIPIING TO BE 4" SCHEDULE 40 @ I/8 "/FOOT (UNLESS SPECIFIED OTHERWISE). HOFM4s 5. THE DESIGN OF TH15 SYSTEM DOES NOT ALLOW FOR THE USE OF A GARBAGE DISPOSAL. �o�'� p R �yG ( IN FEET) G. SEPTIC TANKS AND DISTRIBUTION BOXES WHEN INSTALLED) MUST BE PLACED o ON A MECHANICALLY COMPACTED BASE OF G" OF CRUSHED STONE. " E 1" = 40 No. 1140 7. EXISITNG LEACH PIT TO BE PUMPED, CRUSHED, * REMOVED PER TITLE V. REPLACE WITH MEDIUM CLEAN MEDIUM SAND QfsTEa 8. NO KNOWN PRIVATE WELLS, WITHIN 150 FEET OF PROPERTY LEACHING. sgN+rAR oil- 9. NO WETLANDS WITHIN 150 FEET OF PROPERTY LEACHING 10. NO VARIANCE FROM TITLE V. OR TOWN OR TOWN OF BARNSTABLE BOARD OF HEALTH REGULATIONS REQUIRED 1 1 . REMOVE ALL UNSUITABLE SOILS 5 FEET AROUND LEACHING TO ELEVATION OF 8G.08 OR TOP OF C2 LAYER AND REPLACE WITH CLEAN MEDIUM SAND PER T ITLE V. 51 1 E PLAN �o RICH. �N HOOD o No. 35031 Ct ►��� 1 s isTE� FIR5T FLOOR PROFI LE OF DISPOSAL SYSTEM I S S�� Zc � TOP OF WALL N.T.S. n��Q� V-- SEWAGE SYSTEM DESIGN 2%SLOPE EL. 99.5 -88.75 \/ FOR \\\\/\�\�\\�\/\ ACCESS W/IN G"OF GR \/\/\/� 9"MIN. COVER MIN. " COVE HEALTH AGENT APPROVAL DATE JAN ET DENJAM I N50N 9G.5 \\ ExIST. ON I O I.I (� O TEST tbo$, 2" - /8" ouble Washed Stone ,'lSo'a 10 EXIST 4 FOP.LEVEL 2'LEVEL LEGEND EXIST. 2'LEVEL 20 MILL LANE 1,000 gal D-Box Out 96 0�X8 0 0 0 0 0 � W. DARN5TADLE CHECK SEPTIC TANK(H- I O) GASBAPFLE 6"MIN ° ° `t�r ,� o 0 0 0 0 �8 8 94.0 24 SURVEYED BY: ENGINEERED BY: 97.5 97.33 .8°8.8 - PROPOSED CONTOUR $ ° 1 90 s � �. 8 s I 3/4"- 1 1/2"DouBI F hood Survey group, LLC. Darren Meyer, P-5. `-G"CRUSHED STONE OR COMPACTED PROPOSED NEW WASHED STONE I O MIN 10 EXISTING CONTOUR LAND SURVEYORS REGISTERED SANTITARIAN D13-3 D-BOX (PROPOSED NEW 4BR LEACHING) 18 Route GA P.O. BOX 981 20 MIN. 12.25' DRIVEWAY (33.5'Lx 13'wx 2'D) � SANDWICH, MA 02563 E. SANDWICH, MA 02537 BorroM OF TESTHOLE ELEV. 81.75 FIRM ZONE DATE: 21 OCT05 SCALE: 1" = 40'