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Commonwealth of Massachusetts
Title 5 Official Inspection Form
�= h Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
50 North Winds Lane
Property Address
Kenneth&Irene O'Brien
Owner Owner's Name
information is West Barnstable Ma 02668 5-3-2021
required for 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. Please see completeness checklist at the end of the form.
Important:When filling out forms A. Inspector Information
on the computer,
use only the tab Daniel Hawkins
key to move your Name of Inspector
cursor-do not B&B Excavation
use the return Company Name
key.
374 Route 130
y Company Address
Sandwich Ma 02563
City/Town State Zip Code
, ,. (508)477-0653 S114324
- - Telephone Number License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address
listed above; the information reported below is true, accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined
that the system:
1. ■❑ Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
Dan Hawkins Digitally signed by Dan Hawkins
•'Date:2021.05.0713:0528-04'0o, 5-3-2021
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of
10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note: This report only describes conditions at the time of inspection and under the
conditions of use at that time.This inspection does not address how the system will perform
in the future under the same or different conditions of use.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18
c Commonwealth of Massachusetts
� -............... Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�v
50 North Winds Lane
Property Address
Kenneth&Irene O'Brien
Owner Owner's Name
information is West Barnstable Ma 02668 5-3-2021
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) System Passes:
❑■ 1 have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are
indicated below.
Comments: .
The system was in working order at the time of inspection.
2) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health,will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not
determined,"please explain.
The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
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):
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
i� Subsurface Sewage Disposal System F -g p y Form Not for Voluntary Assessments
50 North Winds Lane
Property Address
Kenneth&Irene O'Brien
Owner Owner's Name
information is West Barnstable Ma 02668 5-3-2021
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes (cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ . broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
3) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
a. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18
I�
c Commonwealth of Massachusetts
�- - � Title 5 Official Inspection Form
.1. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
50 North Winds Lane
Property Address
Kenneth&Irene O'Brien
Owner Owner's Name
information is West Barnstable Ma 02668 5-3-2021
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
c. Other:
4) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
i
Yes No
E O Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ 0 Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
t5insp.doc•rev.726I2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18
Commonwealth of Massachusetts
IS Title 5 Official Inspection Form
F� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
50 North Winds Lane
Property Address
Kenneth&Irene O'Brien
Owner Owner's Name
information is West Barnstable Ma 02668 5-3-2021
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (Cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ 0 Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ❑ Liquid depth in cesspool is less than 6" below invert or available volume is less
than '/day flow
❑ ❑ Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ El Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ El Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ 0 Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
❑ 0 Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ El Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ❑ The system is a cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd.
❑ a 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.
5) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section CA.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
Commonwealth of Massachusetts
�- -� Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
North
50 o Winds Lane
Property Address
Kenneth& Irene O'Brien
Owner Owner's Name
information is West Barnstable Ma 02668 5-3-2021
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered"yes"to any question in Section C.5 the system is considered a significant
threat, or answered"yes"to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate"yes" or"no"for each of the following for all inspections:
Yes No
❑ 0 Pumping information was provided by the owner, occupant, or Board of Health
❑ 0 Were any of the system components pumped out in the previous two weeks?
El ❑ Has the system received normal flows in the previous two week period?
❑ a 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)
❑ El Was the facility or dwelling inspected for signs of sewage back up?
El ❑ Was the site inspected for signs of break out?
E ❑ Were all system components, excluding the SAS, located on site?
ED ❑ 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:
❑ El Existing information. For example, a plan at the Board of Health.
El ❑ 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)]
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18
r
Commonwealth of Massachusetts
q. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
50 North Winds Lane
Property Address
Kenneth&Irene O'Brien
Owner Owner's Name
information is West Barnstable Ma 02668 5-3-2021
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions: .
No design plans 4
Number of bedrooms(design): Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): NA
Description:
No design plans or permits were available at local Board of Health.
Number of current residents: 2
Does residence have a garbage grinder? ❑ Yes No
Does residence have a water treatment unit? ❑ Yes .❑ No
If yes, discharges to:
Is laundry on a separate sewage system?(Include laundry system inspection ® Yes No
information in this report.)
Laundry system inspected? [I Yes F!] No
Seasonaluse? ❑ Yes [E No
Water meter readings, if available(last 2 years usage(gpd)): See below
Detail:
'Well water'
Sump pump? ❑ Yes ❑■ No
Current
Last date of occupancy: Date
t5insp.doc•rev.7/262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
f
f
-- ..._.
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
. ......... to
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
50 North Winds Lane
Property Address
Kenneth&Irene O'Brien
Owner Owner's Name
information is West Barnstable Ma 02668 5-3-2021
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
2. Commercial/Industrial Flow Conditions:
NA
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per d
P Y(gP )
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
I ,
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe below):
3. Pumping Records:
p g
Source of information: Owner- date of last pump is unknown
Was system pumped as part of the inspection? ❑ Yes 0 No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
I
y
t5insp.doc•rev.726/2018 Title 5 0itcal Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18
Commonwealth of Massachusetts
�, Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
50 North Winds Lane
Property Address
Kenneth&Irene O'Brien
Owner Owner's Name
information is West Barnstable Ma 02668 5-3-2021
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System:
El Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no)(if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank.Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed(if known)and source of information:
1994 per asbuilt
Were sewage odors detected when arriving at the site? ❑ Yes X No
5. Building Sewer(locate on site plan):
2'
Depth below grade: feet
Material of construction:
❑cast iron ■❑40 PVC ❑ other(explain):
Distance from private water supply well or suction line: >1 00' from well to SASfeet
Comments(on condition of joints, venting, evidence of leakage, etc.):
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18
Commonwealth of Massachusetts
01,
Title 5 Official Inspection Form
t Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
u
50 North Winds Lane
Property Address
Kenneth&Irene O'Brien
Owner Owner's Name
information is West Barnstable Ma 02668 5-3-2021
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
1'
Depth below grade:
P
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
1
Dimensions: 500gallons
6"
Sludge depth:
3011
Distance from top of sludge to bottom of outlet tee or baffle
3"
Scum thickness
6"
Distance from top of scum to top of outlet tee or baffle
1411
Distance from bottom of scum to bottom of outlet tee or baffle
measured
How were dimensions determined?
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
The tank was in working order at the time of inspection. The tank is in need of pumping
at this time and should be pumped every two years for maintenance.
t5insp.cloc•rev.726/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18
Commonwealth of Massachusetts
a Title 5 Official Inspection Form
t _ F. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
!% 50 North Winds Lane
Property Address
Kenneth&Irene O'Brien
Owner Owner's Name
information is West Barnstable Ma 02668 5=3-2021
required for every
page. City/Town Staie Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap(locate on site plan):
NA
Depth below grade: feet
Material of construction:
❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain):
Dimensions.-
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
NA
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
S
Capacity:
gallons
Design Flow: gallons per day
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18
c Commonwealth of Massachusetts
k1� p Title 5 Official Inspection Form
I a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
50 North Winds Lane
Property Address
Kenneth&Irene O'Brien
Owner Owner's Name
information is West Barnstable Ma 02668 5-3-2021 `
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank(cont.)
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
"Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
9. Distribution Box(if present must be opened) (locate on site plan):
o„
Depth of liquid level above outlet invert
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
The d-box was in working order at the time of inspection.
t5insp.doc•rev.7262018' Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
h
Commonwealth of Massachusetts
d Title 5 Official Inspection Form
- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
t ;
50 North Winds Lane
Property Address
Kenneth& Irene O'Brien
Owner Owner's Name
information is West Barnstable Ma 02668 5-3-2021
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No"
Alarms in working order: ❑ Yes ❑ No"
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
NA
If pumps or alarms are not in working order, system is a conditional pass.
11. Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
❑ leaching pits number:
❑ leaching chambers number:
(3)4'x4'galleries
0 leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18
Commonwealth of Massachusetts
..__..._..._ _::::.
n = F Title 5 Official Inspection Form
la Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
50 North Winds Lane
Property Address
Kenneth&Irene O'Brien
Owner Owner's Name
information is West Barnstable Ma 02668 5-3-2021
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System (SAS) (cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
.The SAS was in working order at the time of inspection. Leaching was dry when viewed.
12. Cesspools (cesspool must be pumped as part of inspection)(locate on site plan):
NA
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.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18
i
Commonwealth of Massachusetts
iEd Title 5 Official Inspection Form
- it Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
50 North Winds Lane
Property Address
Kenneth&Irene O'Brien
Owner Owner's Name
information is West Barnstable Ma 02668 5-3-2021
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
13. Privy(locate on site plan):
Materials of construction: NA
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins.doc-rev.7262016 p Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
1. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
1'
50 North Winds Lane
u -
Property Address
Kenneth&Irene O'Brien
Owner Owner's Name
information is West Barnstable Ma 02668 5-3-2021
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
14. Sketch Of Sewage Disposal System:
Provide a view of the sewage disposal system, including ties to at least two permanent reference
landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters
the building. Check one of the boxes below:
❑■ hand-sketch in the area below
❑ drawing attached separately
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t5insp.doc•rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18
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Commonwealth of Massachusetts
w =- ; Title 5 Official Inspection Form
i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
50 North Winds Lane
Property Address
Kenneth'&Irene O'Brien
Owner Owner's Name
information is required for every West Barnstable Ma 02668 5-3-2021
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
Check Slope
0 Surface water
■❑ Check cellar
❑■ Shallow wells
No GW 4' below SAS
Estimated depth to high ground water: 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:
A hand hole was augured to determine high groundwater. No water was encountered
4' below SAS.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18
Commonwealth of Massachusetts
�F Title 5 Official Inspection Form
.18 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
50 North Winds Lane
Property Address
Kenneth&Irene O'Brien
Owner Owner's Name
information is West Barnstable Ma 02668 5-3-2021
required for every
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
■❑ A. Inspector Information: Complete all fields in this section.
All B. Certification: Signed&Dated and 1, 2, 3, or 4 checked
0 C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4(Failure Criteria)and 6(Checklist)completed
❑■ D. System Information:
For 8: Tight/Holding Tank—Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
s
e .
I -
t5insp.doc•rev.7262018 _ - Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18
No. ......._....... Fas.......................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF LHEALTH
fi /..:�•^ /h...............OF.....N.a. Y1S7.a C%.------------------------.............
Appliratiou for Diopnsttl Works Toustrurtiou r mit
Application is hereby made for a Permit to Construct ()C) or Repair ( ) an Individual Sewage Disposal
�— Location-Address Lot N
FKa k_ �rc� �2.rs 1.1..3..._r e f e....... e_..... .....w:.
........._..
.......-•------•--•--•-
Owner / ) l l� f7QY
!.i(J ess (/LJ f S
w ern 5? '�f � %.....
•- e ...................................••---• ---••---•--•- k
taller Address
Type of Building �f Size Lot7... ......Sq. feet
U Dwelling—No. of Bedrooms........T.................................Expansion Attic ( ) /lbGarbage Grinder ( )
Other—T e of Building No. of persons............................ Showers — Cafeteria
a Other fixtures ------------------------------------------------------"-----------------------------------------------
.-.--------------------------------
•-----------
d
W Design Flow......................J� ..............gallons per person per day. Total daily flow.........._.._.. `U...............gallons.
WSeptic Tank—Liquid capacity/,U..gallons Length/Q:16..___ Width=. ...... Diameter................ Depth_.��-6_....
x Disposal Trench—No.�.�2&3S.... Width...V............ Total Length_.___.......... Total leaching area.._._. 9-----sq. ft.
3 Seepage Pit No..................... Diameter.................................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box (K) Dosing to k ( ) f
'-' Percolation Test Resul,ts// Performed by------ .e'4'!i�lca..... ids °rb ... ...... Date_._.?/ 9 b11Q._...
aTest Pit No. I....7-........minutes per inch Depth of Test Pit.................... Depth,,.to groun ........................
Test Pit No. 2................minutes per inch Depth of Test Pit---&.......... Depth to gr ��..
04 -----_:_.. ....... .........
`y- �--•--------------------------------------------------- � RI►�PH
ZEE--•.•••.
U ...........................•............................................. -•- -- ............
KtN .._ ._
.................................................. ------------------•-----•--•---•--••-•-••--•••--------------------------•----•-------•------------.--- 9 .3T12
UNature of Repairs or Alterations—Answer when applicable----------------------------------------- .......
C
Agreement:.
The undersigned agrees to install the aforedescribed Individual Sewage Disposal Sy em in accordance with
the provisions of TITLE 5 of the State Environmental CAde—The undersigned urther agrees not to place the
system in operation until a Certificate of Compliance has en ue y the bo of health.
ne .......... .... ..::......... . ................ ........................... ---------------------- ......---------
Pate f
ApplicationApproved By ..... ...... ........................................... ...................................:.:.:_.:............. ...Dacec1
Application Disapproved for the following reasons: .-:............................. ............................... .....................................--...------------
----- ------------------------------------- ........................................... ...............: --...-- ---....----
ace
Permit No.
..------�-�...........................................: Issued ..........................................................-------...
Dace
No......................... Fizz.............................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...............OF.....RC.ri}r?a/e,b ',
Appliratiun for Uiipuual Works Tonstrur#inn Errant
Application is hereby made for a Permit to Construct (`zt) or Repair ( ) an Individual Sewage Disposal
System at: r I
.... •• -- --- -• ..
7Location Address j o Lot N.o.? f�
�t'.rc/ j'�� �{ri � fC rt�f. �.�°J, ram, >i " to IJe
___. ...... .............. ----.........---....... -- ..... . --------------•--•-_. .......--
� �r Owner �j Addreq f
............. •--•--
Installer Address r'
Type of Building / Lot.
�x�
Size Lot._ J ......Sq. feet
Dwelling—No. of Bedrooms.............................................Expansion Attic ( ) ' Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Otherfixtures - ------------------------------------------------------------------------------------ --------------------
W Design Flow.......................:._......__..._..gallons per person per day. Total daily flow..................�.�-:.............._gallons.
WSeptic Tank—Liquid capacity/r !..gallons Length Z :C..._ Width. _: ..... Diameter................ Depth.,` _6.._.
x Disposal Trench—No. . . ....4.... Width....1�............ Total Length....... ........ Total leaching area....` `�5...sq. ft.
3 Seepage Pit No..................... Diameter---_................ Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box (x) Dosing tank ( ) r
Percolation Test Results Performed by....... C1(� '_r+i_lt ..........---....o..:b?%(.....:..._.... Date_...._........�___.....��....-
,`4a Test Pit No. I.....I.......minutes per inch Depth of Test Pit--__/.�........_ Depth to ground water......F/(jr`.`--.._.-
(i, Test Pit No. 2................minutes per inch Depth of Test Pit---- ......... Depth to ground wat i')Cj.'.�_.
04 ........L --------•- --------------•---••------•--...-•-------........................... dR ........
0 Description of Soil............ .C? ........... ' . �.....��.�U ...............................................................
�..
------------ ---------------------- ----------------------- -------------------
-•---------------
•------------------------------------------
--------------
RAt.PH
W .....---•--•------------•------------------•---•-------------------•---------...-----------------•-------------------•---------••--•--------------•---------•••. -----F3At4KtN.....
U Nature of Repairs or Alterations—Answer when applicable--------------------------------------------------------- 4 .......am .�
•--- --••••...................••-••.................-•------•---•--.....-------•--•-----------------------------------------•••--------•----------........ T
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in actor ante with
the provisions of TITLE 5 of the State Environmental 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.
Signed ............................. .. ........................ . . ........................... ......................................
_ Date.
ApplicationApproved By ....................... ...--- -:............."..`.............. ........................ --....----... ......................
Dare "
Application Disapproved for the following reasons: ...................... ........................................................ ................... ............................
.................................................................................:............ ..................................... ................................................................ ........................................
Dace
PermitNo. ................................................................... Issued ...................................................................
Dare
THE COMMONWEALTH OF MASSACHUSETTS
_ BOARD OF HEALTH
-.j '. ... .... of ......1 )r�(>.Is- �,.t;%.................................................
01.1jertifirate of (11IIritylialare
THIS IS TO CERTIpFY, That dthe Individual Sewage Disposal System constructed ( �c ) or Repaired ( )
by .............................._......------ --- ;.... ..........
f Installer
at ...................n%L)j........... .....-....... .Jrl.r�. �.. -{ .J. 7cUJ (% "
<... -t............................ ............... ..........
has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in
the application for Disposal Works Construction Permit No. ..........................._ .f. l- `.... dated .....--....--.......................-...........
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATIS ACTORY.
DATE........ "``.... .... ��.......... ........ .......................... Inspectot"�- ;.�/. � �
THE COMMONWEALTH OF MASSACHUSETTS
BOARD /0F HEALTH
Q O
No..`............ ..... FE&A
Disposal Works Tnnstrudiun VarAit
Permission is hereby granted............ ! �� /'-'r I I m'�: .... _.1.....
to Construct O or Repair ( ) an Individual Sewage Disposal System ~
atNo.. ` �.. .............. U.Y'"�rt...._. t.1,trfyf----.... ................................................................................ .............
Street �y�1
as shown on the application for Disposal Works Construction Per It Nib..... ._(_�_ .. Dated..........................................
�---..-----.-•. ................................
s Board of He th
DATE......=.. s..__ `. � .
Form 1255 H&W HOBBS&WARREN ree Publishers
a Department of Environmental Managernent/Division of Water Resources
WELL COMPLETION REPORT
WELL LOCATION GEOGRAPHIC DESCRIPTION ,.
Address
_ l . S E W of
M.) (ci�rcl
City/Town Is
Well owner e--I ��--° RYM. 0 Iroa
al-
Address N SOW
W of
fnN.m tenthsl rclel
Board of Health permit obtained: yes ❑ no ❑ "'tersecr: w/�° M f id
WELL USE WELL DATA
Domestic Public❑ Industrial ❑" Total well depth.ft.
Monitoring❑ Other Depth to bedrock—ft.
Water-beating roc lunconsolidaled material:
Method drilled --
Date drilled _ Description
CASING Water-bearing zones:
.-►
Type— 4 From To
2) From To
Length ft. Dia(.I.D.) V in.
3) From To
Length into bedrock 01,00011-1l f t Gravel pack well: dia.
l• �Protective well sea /-�'
.Screen: dia.
Grout-El Other Slot e n q-t h!r—f r o mM toy
STATIC WATER LEVEL(all wells)
Static water level below land surface II. Date
WELL TEST(production wells)
Drawdown - ft, altar pumping' Iir. min:at gpm
How rnea.sured Recovery I I. after—hr. min.
0
LOG of FORMATIONS. COMMENTS :
Materials From To
Driller
Firm
Address A A,4 14<A A)
City/Town .ate 6r
Supervising Driller Reg.ttrtf '
f
i care of vi ervrslnIN',b r
?lease pnnr firmly B BARD;, Of HEALTH -COPY.,'°.
OFFICE LABORATORY
t 1498 HIGH STREET ' 176 PLYMOUTH STREET
BRIDGEWATER,MA 02324 BRIDGEWATER,MA 02324
OLIVEIRA ENVIRONMENTAL LABORATORIES, INC.
WATER-WASTEWATER-FOOD-DAIRY PRODUCTS
CHEMICAL&BACTERIOLOGICAL ANALYSES
Telephone(508)697.2650
FAX(508)697-0163
July 27, 1993
L. Wile & Son Drilling Co.
11 Annasnappitt Drive
Plympton, Mass. 02367
Source: Well Water - Drilled Well - 4 inch PVC - 185 feet deep - producing 25 gals/min.
Located on the O'Brian property - Lot 43 Northwind Lane - West Barnstable, MA
Analysis Number: 93-07-2452 Analysis Date: 7/26/93
Compound (Regulated) Result MCL Detection Analytical
ug/L ug/L Limit ug/L Method
Benzene ND 5.0 0.5 . 503.1
Carbon Tetrachloride ND 5.0 0.5 502.1
1,1-Dichloroethylene ND 7.0 0.5 502.1
1,2-Dichloroethane ND 5.0 0.5 502.1
para-Dichlorobenzene ND 5.0 0.5 502.1
Trichloroethylene ND 5.0 0.5 502.1
1,1,1-Trichloroethane ND 200.0 0.5 502.1
Vinyl Chloride
ND 2.0 0.5 502.1
Monochlorobenzene ND 100.0 0.5 502.1
o-Dichlorobenzene ND 600.0 0.5 502.1
trans-1,2-Dichloroethylene ND 100.0 0.5 502.1
cis-1,2-Dichloroethylene ND 70.0 0.5 502.1
1,2-Dichloropropane ND 5.0 0.5 502.1
Ethylbenzene ND 700.0 0.5 503.1
Styrene ND 100.0 0.5 503.1
Tetrachloroethylene ND 5.0 0.5 502.1
Toluene ND 1000.0 0.5 503.1
Xylenes (total) ND 10000.0 0.5 503.1
OFFICE LABORATORY
1498 HIGH STREET 176 PLYMOUTH STREET
BRIDGEWATER,MA 02324 BRIDGEWATER,MA 02324
OLIVEIRA ENVIRONMENTAL LABORATORIES, INC.
WATER-WASTEWATER-FOOD-DAIRY PRODUCTS
CHEMICAL&BACTERIOLOGICAL ANALYSES
Telephone(508)697-2650
FAX(508)697-0163
PAGE 2
Compound (Unregulated) Result MCL Detection Analytical
U /L U /L Limit u /L Method
Chloroform 3.7 ---- 0.5 502.1
Bromodichloromethane 2.5 ---- 0.5 502.1
Chlorodibromomethane 1.3 ---- 0.5 502.1
Bromoform 0.8 ---- 0.5 502.1
m-Dichlorobenzene ND ---- 0.5 502.1
Dichloromethane ND ---- 0.5 502.1
Dibromomethane ND ---- 0.5 502.1
1,1-Dichloropropene ND. ---- 0.5 502.1
1,1-Dichloroethane ND ---- 0.5 502.1
1,1,2,2-Tetrachloroethane ND ---- 0.5 502.1
1,3-Dichloropropane ND ---- 0.5 502.1
Chloromethane ND ---- 0.5 502.1
Bromomethane ND ---- 0.5 502.1
1,2,3-Trichloropropane ND ---- 0.5 502.1
1,1,1,2-Tetrachloroethane ND ---- 0.5 502.1
Chloroethane ND ---- 0.5 502.1
1,1,2-Trichloroethane ND ---- 0.5 502.1
2,2-Dichloropropane ND ---- 0.5 502.1
o-Chlorotoluene ND ---- 0.5 502.1
Bromoberzene ND ---- 0.5 502.1
1,3-Dichloropropene ND. ---- 0.5 502.1
MCL = Maximum Contaminant Level
ND = None Detected. (Below minimum detectable level - MDL)
Tested by Lab #MA022
Surrogate Recoveries
Compound % Recovered QC Limits
2-Bromo-l-chloropropane 89 80-120
Fluorobenzene 100 80-120
Sample collected by L. Wile - 7/22/93.
Samples relinquished to laboratory by D. Reese of L. Wile & Son - 7/22/93 at 1600 hrs.
95
Director
OFFICE LABORATORY
1498 HIGH STREET 176 PLYMOUTH STREET
BRIDGEWATER,MA 02324 BRIDGEWATER,MA 02324
OLIVEIRA ENVIRONMENTAL LABORATORIES, INC.
WATER-WASTEWATER-FOOD-DAIRY PRODUCTS
CHEMICAL&BACTERIOLOGICAL ANALYSES
Telephone(508)697-2650
FAX(508)697-0163
July 27, 1993
L. Wile & Son Drilling Co.
11 Annasnappitt Drive
Plympton, Mass. 02367
Source: Well Water - Drilled Well - 4 inch PVC - 185 feet Deep - producing 25 gals/min.
(static water level 133 feet)
Located on the O'Brian property - Lot 43 Northwind Lane - West Barnstable, MA
Analysis #93-07-2452
Coliform Count
/100 ml @ 35 C
0
Membrane Filter
S.P.C./ml
@35C 2
Color (APC units) 15.0
Sediment none
Turbidity (NTU) 3.60
Odor. N.O.O.
Taste satisfactory
pH 6.80
Specific Conductance 132.
micromhos/cm
mg /liter
Total Alkalinity (CaCO,) 13.0
Free CO, 4.03
Total Hardness (CACO,) 38.0
Calcium (Ca) 9.60
Magnesium (Mg) 3.67
Sodium (Na) 11.6
Potassium (K) 0.97
Total Iron (Fe) 0.09
Manganese (Mn) L 0.01
Silica (Si00 11.8
Sulfate (SO,) 7.40
Chloride (CI) 33.5
Nitrogen- Ammonia 0.03
Nitrogen - Nitrite 0.005
Nitrogen - Nitrate L 0.50
Copper (Cu) _
L = less than
N.O.O. = No Odor Observed
Sample collected by L. Wile - 7/22/93.
Sample relinquished to laboratory by D. Reese of L. Wile &. Son - 7/22/93 at 1600 hrs.
Bacteriologically, this well water is of a satisfactory sanitary standard and is suitable
for drinking and domestic purposes.
Chemically, this well water meets the standards for all of the chemicals tested.
s
Director
F83384-1
The Standard Plate Count indicated the general bacterial population of the well at the time of collection.
Coliform Group Bacteria:
Significance
The coliform group bacteria includes organisms found in the intestinal tracts of warm blooded animals, birds,decaying organic matter(hay,
leaves, wood, etc.), the top 2 to 3 feet of the soil, lakes, ponds, brooks, rivers, drainage and types of vegetation.
Because the organisms can cause some illness; because the presence of coliform organisms in the water suggests that other more harmful
organisms may be present, water containing one or more coliform group bacteria per 100 ml of sample should not be used for drinking or
cooking purposes unless boiled 5 minutes or disinfected by other means.
This bacteria is of animal origin(intestinal tract)and may be considered as closely associated with disease causing organisms.On this factor,
none should be present.
Color — APC Units- Ground water ought to be practically free from color. For attractive water- color should not exceed 15 units.
Turbidity — NT Units- Recommended limit not to exceed 5 units.
Odor Fr Taste — For water to be of high quality, the water should be odor free and taste good.
pH — The pH value defines the concentration of free hydrogen ions in solution. Expressed on a scale extending from 0 or very acid to 14 or
vey alkaline with 7.0 being neutral.
Specific Conductance — Conductivity is a good criterion for measuring the degree of mineralization and assessing the affect of diverse ions
on chemical equilibria.
Total Alkalinity — The alkalinity of this water represents its content of carbonates and bicarbonates.
Free Carbon Dioxide — Well water having a low pH and a Free CO, level in excess of 50. mg/I will be corrosive to iron, bronze, brass and
copper tubing and fittings.
Total Hardness — Standard not to exceed 50. mg/I. Waters having a hardness level of 50 to 100 are in the medium hardness range, over
100 very hard.
Calcium -- Calcium contributes to the total hardness of water.Appreciable amounts of calcium salts break down on heating and form scale
in boilers, pipes and cooking utensils.
Magnesium — Magnesium is a common constituent of natural water. Magnesium and calcium ions are principal contributors to water hard-
ness. Concentrations in excess of 125 mg/I can exert a cathartic and diuretic action.
t
Sodium—Component of Salt.
Potassium — Potassium concentrations in drinking water seldom exceed 20. mg/I.
Total Iron — Standard not to exceed 0.3 mg/I.
Manganese — Standard not to exceed 0.05 mg/l.The principal reason for limiting the concentration of manganese is to reduce esthetic and
economic problems.
Silica — Silica content of natural water is most commonly in the 1 to 30 mg/I. Silica in water is undesirable because it forms difficult to
remove silica scales.
Sulfates — Standard not to exceed 250 mg/I.
Chloride — Standard not to exceed 250 mg/l.
Nitrogen — Ammonia is present in variable concentrations in many surface and ground waters. Its occurrence in ground water is generally a
result of natural reduction processes.
Nitrogen - Nitrite — Nitrite in water poses a health hazard, but fortunately seldom occurs in high concentrations. Waters with a nitrogen -
nitrite concentration over 1 mg/I should not be used for infant feeding.
Nitrogen - Nitrate — Standard not to exceed 10. mg/I. Nitrate, in high concentrations can and do cause methemoglobinemia or so-called
nitrate poisoning in infants. Water with 10 or more mg/I of nitrate is unsatisfactory and is not considered safe for drinking or cook-
ing. It is especially dangerous to children and should never be used in infant formulas.
Copper — Standard not to exceed 1.0 mg/I.
Lead—Standard not to exceed 0.015 mg/1.
Arsenic—Standard not to exceed 0.05 mg/1.
Tannin—Tannin may enter the water supply through the process of vegetative degradation.
F83384-2
® TOWN OF BAARNSTABLE
LOCATION9 �G' ` SEWAGE if
VILLAGE - 4& ASSESSOR'S MAP & LOT , 4751/
INSTALLER'S NAME & PHONE NO.
SEPTIC TANK CAPACITY /
LEACHING FACILITY:(tppe) (size) 4
NO. OF BEDROOMS RIVAT �WE OR PUBLIC WATER
" BUILDER OR OWNER
DATE PERMIT ISSUED:
9 J
DATE COMPLIANCE ISSUED: '°''/ "''
VARIANCE GRANTED: Yes No
f
Vol
F ,
10
r,
Fee----1--�-----------
BOARD OF HEALTH
TOWN OF BARNSTABLE
Zipprication-*rVell Con5tructionPermit
Application is hereby irtade for a permit to Co truct ( ), Alter ( ), or Repair ( )an individual Well at:
----- ——-- ------- ------------------------------------------ —— ------
Location — Add r s 1. AssessorsMap and Parcel
Owner Add
Installer — Drill. Address
Type of Building
Dwelling ----- --- - -- —- - -
Other - Type of Building----------------------------------- No. of Persons-------------------------------- --- —
Type of Well —-— L-rr-----�"-
Purposeof Well--------------------------------------------------------------
Agreement:
The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The
Town of Barnstable Board of Health Private Well Protection Regulation — The undersigned further agrees not to
place the well in operation until Certificate of Compliance has been issued by the Board of Health.
Si ne - / LPL__ _ _ --------- —_____—
date
Application Approved By-------- 3• �1-
--- — date
Application Disapproved for the following reasons:------------------------------------------------------------------------------__________-----
--------------------------------------------------------------------------------------------------------------------------- —
date
Permit No. -__�__- - — Issued------------------------------------------— --- - —__— -
--------------
date
i
BOARD OF HEALTH
TOWN OF BARNSTABLE
(Certificate Of Compliance
THI)IS TO GEIVIFY, T the Individual Well Constructed ( ), Altered ( ), or Repaired ( )
y ^
---
Installe
/
has been installed in accordance with the provisions of the own of Barnstable Board of Health Private Well Protection
Regulation as described in the application for Well Construction Permit No.WTI3—=-L-_�-Dated---------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL
SYSTEM WILL FUNCTION SATISFACTORY.
DATE— —- - --- - - --- --------_--_ Inspector- -- - - - --- -— — --- --
No.— Fee----'a-?- -----------
I BOARD OF HEALTH
TOWN OF BARNSTABLE
3ppricationforlVell Con5tructionpermit
Application is hereby made for a permit to Construct ( ), Alter ( ), or Repair ( )an individual Well at:
- - -— —- -- CA/'Z-s-t----B -------- ------------------------------------------------------------------------------------------
Location — Address • ' Assessors Ma and Parcel
P
��--------, 1�a Rah -Cur_-' ' ` - - ` } �� °----/�.� l �`r1�,+�_ I A� .0
Owner Address—
tC+�� Installer — Driller" Address
Type of Building
Dwelling------------------------------------------------------------
Other - Type of Building---------------- - ---- No. of Persons----------------------------------------------------------
Type
of Well--T- -�-j-V C--— __ -----------------------------------
- Capacity- - - - --
Purpose of Well--------------------------- --- ----
I 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----6 /1 ,.�t -
--------------------------------------
date
Application Approved By --�V t ------------------------------------ --------7 a e-
Application Disapproved for the following reasons:------------------- -------------------------------------------_______—__________________
---------—--------------------------------------------------=----------------------------------------------------------------------------------------------
--
------------
f date
Permit No. / ----'=--------------------------------- Issued--------------------------------------------------------------------------------------
----------
date
BOARD OF HEALTH
TOWN OF BARNSTABLE
Certificate Of Compliance
THIS IS TO CER�171FY, Thak the Individual Well Constructed Altered or Repaired
bYc� - - —------------------------------------------------------------
�/ /� f Installe >
at C)1--7"--�-------/If_/�____'�_y'_l____-�.�t?�4/jQ---��/�..� -- ,,/ ��t�� 1�f
"r__ ____-______-_________ _r____- _____-___---------------______-__________________
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.W-;'s-.__1y-a_Dated---------------------------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL
SYSTEM WILL FUNCTION SATISFACTORY. r
DATE--------------------------------- ------- Inspector----------------------------------------------------------------------------
BOARD OF HEALTH
TOWN OF BARNSTABLE
Very Congtructioni3ermit ,
Fee --��-------------
r
Permission is hereby ---------------- ���
fo Construct (1)�Alter ( ), or Repair ( ) an Individual Well at:VO-f- (>!lvo--------------
No. �_, -akk------- -------------------------------------------------------------------------------------------------------------------------
Street
as shown on the application for a Well Construction Permit
No.---------------------------- ---- Dated-----------—--------------------------------------------------------------------
�`----------------------------- 3
---------------------------------------------------
Board of Health
DATE ------------------
_JT ,� ttie l�Ir'
s
r /�i�ECAST SEPTIC TANK - -.-��� �� ' ,t,,',�� PRECAST LEACHING GALLEY
(not to sco%)
3
,
�o
_ i I s l ❑ Q Cr O Cj 11 11 r
% -
�- /i/ L 3„WASHED ) 0 a a r� �❑ d i1 3,� J
WASHED
.. o STONE //8"70//2' !' ❑ ❑ a I- o a ct o STONE-//B„70/�„ �q
LOCUS PLAN
SCALE WASHED wasHm
^ ' V
_
STONE j/4 710 1112 SMWE- 14"M IW 1A
-
J/ /
G - TF: `NE /QUIL? DEP "t1 Of T
1 ,rE SEPTIC ;LINK /S 5 FEE7,
`rE. JU7, 'T -TAL L t } :"FND 19"BELOW THEFL OW L,'NE.
C
C, l.(J ,
sEcrr
ON THRU SYSTEM
not
sc°'el GENERAL NOTES
r { C MH COVER TO W/TH/N /<"OFF/N/SH GRADE
�� _/��>, _ - l l ALL CONSTRUCT/ONTO CONFORM TO TITLE 5 OF THE
MA SSACHUSET TS STATE ENVIRONMENTAL CODE A ND THE
f d n 4"0 G/. OR Sch 4 '
— _ BOARD OF HEALTH REOUIREMENTS FOR THE TOWN OF u �
-i 21 NO PERMANENT STRUCTURE MAYBE CGIAISTRUCTED OVER
40PV.0 ��
� � olsr eox 1 ` THE/00% D(PANSION AREA.
�i �
3) THE DESIGN OF TH/S SYSTEM DOES NOT PERMI T THE
ANKSE T LEACHING
GALLEYS USE OF GARBAGE DISPOSAL UNITS.
4) CONFIRMATION OFCOIV57RUCTION/N ACCORDANCE WITH THIS
r PLAN /S REQUIRED. THIS OFFICEAND THE LOCAL BOARD OF
--/�,- -- , WASHED STONE HEALTH SHALL BE NOT/,F/ED PRIOR TO BACKF/LLING
(min. 20, — — — — THIS SYSTEM
/ I 5) SEPTIC TANKS SHOULDBE/NSPECTED AND CLEANED ANNUAL .
I O\
6) GREA SE TRAPS SHOUL D BE INSPECTED MON THLYA ND SHALL
BE CLEANED WHEN THE LEVEL OFGtWASE/S25'o OF THE
EFFECT/VE DEPTH OF THE TRAP OR A LEAST EVERY
it it THREE MONTHS.
PROPOSED FLOW LINE GRADES AS BUILT GRADES 71 rONSTRUCT/ON OF GALLEY OPEN JOINTS OR
lN'V. A�T FOUNDA TION � '`�
IN U i = ��
PERFORATED WALLS IN MANNER TO H4EVENTO/SPLACEM
t INV. INTO SEPTIC TANK 112 1�6 AN INLET MUSTBEPROVIDED EVERY 20'(MINIMUM)
f sav �1 . s�F " INV. OUT OFSEPTIC TANK '
/� � 1= B1 /F UNSU/TABLE MATERIAL IS FOUND, OR /N VERT OF DIST.
All l 7o� J J' U 4 a t 1 CX �1 r�� �/}2 +1 C�7G,nk � � � 1 f�� < �f
I* r� ,NV UNTO Dls r. BOX
/ ,) PIPES ARE ABOVE OR /N THE TOP AND OR SUB SOIL_
h I
OWTOF DIST BOX J ALL TOP SOIL,SUB SO IL,AND UNSUITABLE MATER/AL TO
INV lIWTO LEACHING GALLEYS BE REM ED TO ELEVATION AS PER SO/L L
k! " ` _ y `'�' ` tt) �._Hy - , N BOT7'04f OF LEACHING GALLEY � -�- -�(% AND FOR A DISTANCE OF l � FEET /N ALL
ONE._ BOTTO/M OF STONE � t � `:✓"� DIRECTIONS FROM LEACHING SYSTEM THEN REPLACED
WATER TABLE ;' W/TH CLEAN SAND FREE OF SILTS, AND DEBRIS, AND
HAVING A PERCOLATIIDN RATE OF LESS THAN 2M/N./
✓} lit} 1 Nc,�Se _ INCH BEFORE AND AFTER PLACE/IIENT.
0.� INSPECTION SCHEDULE
SOIL LOGS ' 6U 7& 0 AFTER EXCAVATION OF THE TOP SOIL , SUB SOIL, AND
r OR THE UNSUI TABL E MA7ER/A L, BU T PRIOR TO
t — — c n, { J T.P. l T. P 2 T.P. 3 T. P 4
V `\ } ,•r
" THE PL ACEMENT OF THE FILL.
2) A FTER PLACEMENT OF THE CL EA IV FIL L BUT PRIOR
/•� TO THE INSTALLATION OF THE SYSTEM.
oD ' 3)FINAL INSPECTION FOR 'AS BU/LT"CERTIF/CAT/UU
;� � � � �JbG.ui( ��0 n I
TO THE BOARD OF HEALTH. )
t
Ttc�4. Frye •-
R o
•
_ ffI 5
:
PERCOL ATION RATE OF V M/NU TES / I NCH
PRESENT�E'NT DURING TESTS ON
��'" - --,-.,�---�•,.,..,,. / �)") �(�CrJ AGENT• Liy"
SLOPE CALCULAT/ON
T� �, r
DESIGN CRITERIA DISTANCE USED /S MEASURED BETWEEN
1p t)' COYVTOUR INTERVAL B
BEDROOM DWEL L I NG AT HORIZONTAL DIST. = X VERTICAL DROP= Y
BENCH MA f' G.PS.D = � o G.P D.
of ,,ors SLOPE = Y = _
GALLEYS /N A 11 X I� X` V D TRENCH
JC�or--PH
E.
r S/DEWALL AREA=�( S.F X 2 U0 G./SF= G. - -
WE-130Y lit_ _�,, t d, .� : ,_X?? i �;, ��
_ / , ; BREAK OUT D/ST.- SLOPE (x� /50
� Na. 2E7�f � BOTTOM AREA = -�.-t—SFX ,•- ,^ G./S.F. - � G. -
TOTAL DAILY CAPACITY- ' GALLONS
" x /50
�Fs..� TOTAL AREA = S.F. BREAK-OUT D/ST= FT.
' SANITARY SYSTEM /N W 8 � 0/ 1
DRAWN FOR: :, 'i" ` - V
DESIGNED BY,, VGU Ir/n 0 f S Webby CO.
DRAWN BY : , ENGINEERS
` LAND SURVEYORS
CHECKED BY: k L COUNTY ROAD PL YMPTON, MASS_
APPROVED BY:
DATE o�ETEO DESCRIPTION BY
EW
REVISIONS � PLAN DATE . ��JI � `�j I0'`�'��'�, SCALE:
AAW
VW ?3