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HomeMy WebLinkAbout0163 PERCIVAL DRIVE - Health 163"Percival Drive W. Barnstable„ F/R A = 110 001012 n n Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 163 Percival Drive c•.: v Property Address ' tit Jim Macurdy Owner Owners Name information is West Barnstable MA 02668 8-5-19 required for every ... page. City/Town State Zip Code Date of Inspection P. 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. 11111 ``1.Xv`OF fAff�lq��i�i Imngoutf When A. Inspector Information S'� ��16 3 filling out forms G on the computer, JAMES u' use only the tab James D.Sears a: key to move your Name of Inspector U cursor-do not Ca ewide Enterprises i'.o o• '� use the return key. Company Name (�•..,, , ..• G ``� 153 Commercial Street INS? ICI Company Address Mashpee MA 02649 CityfTown State Zip Code 0 508-477-8877 S1623 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: I. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 8-6-19 spectors 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. 15insp.doc•rev.712612018 Title 5 Official Inspecdon Form:Subsurface Sewage Disposal Syptem•Page 1 of 18 l, a5ed YPJ dH 0£:LO 61.0Z 60 6ntf f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form •Not for Voluntary Assessments 163 Percival Drive Property Address Jim Macurdy Owner Owner's Name information is required for every West Barnstable MA 02668 8-5-19 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: ® 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 system is a 1500 Gal Tank D Box and three Chamber's. 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 lank 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): I i 151nsp.doc•rev.7126/2018 Title 5 Official Inspection Form:Subsurface,Sewage Disposal System•Page 2 of 18 Z a6ed xeJ dH 0£:LO 660Z 60 6rf Commonwealth of Massachusetts Title 5 Official Inspection Form U9163 Subsurface Sewage Disposal System Form •Not for Voluntary Assessments v Percival Drive Property Address Jim Macurdy Owner Owner's Name information Is required for every West Barnstable MA 02668 8-5-19 page. City/Town slate Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditlonally 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: I5insp.doc•rev.7rA12018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 E a5ed xeJ dH OE:LO 660Z 60 6nbr Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 163 Percival Drive Property Address Jim Macurdy Owner Owner's Name Information is required for every West Barnstable MA 02668 8-5-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summafy (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: 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 15insp.doc-rev.712612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18 abed xeJ dH 0£:LO 61,0Z 60 5nV c� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form •Not for Voluntary Assessments 163 Percival Drive Property Address Jim Macurdy Owner Owner's Name information is required for every West Barnstable MA 02668 8-5-19 page, City/Town State Zip Code Date of Inspection C. Inspection Summary (cant.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in ownspast is less than 6"below invert or available volume is less than 1/2 day flow.4 MIUMvZ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS,cesspool or privy is below high ground water elevation, ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ® 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 ayes"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 I I 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 5 a6ed xeJ dH OE:LO 660Z 60 6ny Commonwealth of Massachusetts Title 5 Official Inspection Form f Subsurface Sewage Disposal System Form Not for Voluntary Assessments 163 Percival Drive Property Address Jim Macurdy Owner Owner's Name information is required for every West Barnstable MA 02666 8-5-19 page. CityRown 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 ❑ ® 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)] t51nsp.doc•rev.,7126=18 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 9 a6ed xed dH 0£:LO 660Z 60 6rV Commonwealth of Massachusetts Title 5 Official Inspection Form , Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 163 Percival Drive Property Address Jim Macurdy Owner Owner's Name information Is required for every West Barnstable MA 02668 8-5-19 page. Cityffawn State Zip Code Date of Inspection D. System Information 1. 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 Description: 1500 Gal. Pit D Box and Three Chambers. 2 Number of current residents: 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? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage(gpd)): Well Detail: Sump pump? ❑ Yes ® No Present Last date of occupancy: Date 19nsp.doc•rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page T of 18 L a5ed xed dH 0& O 660Z 60 6rnd Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form •Not for Voluntary Assessments 163 Percival Drive Property Address Jim Macurdy Owner Owner's Name Information is re west Barnstable MA 02668 8-5-19 wired for every ry page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercialflndustrial 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 Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: 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: Source of information: NA Was system pumped as part of the inspection? ❑ Yes ® No If yes,volume pumped: gallons How was quantity pumped determined? Reason for pumping; t5insp.doc•rev.7/26/2015 Title 5 01fidal Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 9 a5ed xed dH OE:LO 660Z 60 6nd Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form•Not for Voluntary Assessments 163 Perciva l I Drive u� Property Address Jim Macurdy Owner Owner's Name information is required for every West Barnstable MA 02668 8-5-19 page. City/Town state Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank,distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval, ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: 2003 Permit #2003-039. Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): 46" Depth below grade: feet Material of construction: ❑ cast iron ®40 PVC ❑other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Pipeing is 4"PVC SCH -40. t5insp.4ac•rev.7/26=18 Tide 5 Oftal Inspection Form:Subsurface Sewage oisposel Syslem Page 9 of 18 6 a5ed xed dH I•E:LO 61.02 60 6nb' Commonwealth of Massachusetts 1Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 163 Percival Drive Property Address Jim Macurdy owner Owner's Name information is required for every West Barnstable MA 02668 8-5-19 page. CilyfTown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): 3' Depth below grade: feet Material of construction: ®concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No 1500 Gal. Precast H-10 Dimensions: 2" Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 28" 1 Scum thickness Distance from top of scum to top of outlet tee or baffle 8" Distance from bottom of scum to bottom of outlet tee or baffle 17 How were dimensions determined? Asbuilt-Plan-Tape Sludge Judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage,etc.): Tank at working level.Tank at 3' below grade wlinlet cover at 6". In and outlet Tee's. No sign of leakage or over loading t5insp.doc-rev.,7/26/2018 Title 5 Official Inspection form:subsurface Sewage oisposal System-Page 10 of 16 ii 0l, a6ed xeJ dH 1,&LO 61,0Z 60 617TV <el\� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form •Not for Voluntary Assessments v''w 163 Percival Drive Property Address Jim Macurdy - Owner Owner's Name information is MA 02668 8 5-19 required for every west Barnstable page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. 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.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day thinsp.doe•rev.7MI201 B Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 1E a5ed xeJ dH 6£:LO 6602 60 5nV I `y Commonwealth of Massachusetts Title 5 Official Inspection Form 0 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 163 Percival Drive v„ Property Address Jim Macurdy - Owner Owner's Name information is West Barnstable MA 02668 8-5-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank (cost.) 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): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D Box is 16"x21"-32"below grade w1cover at 15". Box is clean and solid w/three line's out.No sign of over loading or solid carry over. t5insp.doc•rev.T12612018 Title 5 Otficim Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 Z6 a6ed xed dH 1,610 660Z 60 5nV I Commonwealth of Massachusetts :. Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 163 Percival Drive Property Address Jim Macurdy Owner Owner's Name information is required for every west Barnstable MA 02668 8-5-19 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.): " 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: ® leaching galleries number: 3 I ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: 15insp.doe•rev.7126M18 Title 5 Ot6del Inspection Form:Subsurtace Sewage Disposal System Page 13 of 18 abed xed dH OLD 61.0Z 60 5nV Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 163 Percival Drive Property Address Jim Macurdy Owner Owner's Name information is West Barnstable MA 02668 5-5-19 required for every City/Town Mown State Zip Code Date of Inspection page. y 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.): Leaching is three 500 Gal.Dry well chamber's. Chamber's are at 43"below grade wlcover at 8". 6"water wlno sign of over loading No high stain line 12. 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.): t5insp.doc-rev.71612018 Title 5 Offlaal Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18 �6 a5ed xeJ dH Z£:LO 660Z 60 6171d Commonwealth of Massachusetts Title 5 Official Inspection Form < Subsurface Sewage Disposal System Form •Not for Voluntary Assessments 163 Percival Drive Property Address Jim Macurdy Owner Owner's Name information is required for every West Barnstable MA 02668 8-5-19 page. Cltyl7own State Zip Code Date of Inspection D. System Information (cont.) 13. 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.): t5insp.doc•rev.7!2612018 Tile 5 Official Inspection Form;Suosurrace Sewage Disposal system•Page 15 of 18 56 a6ed Yed dH H10 660Z 60 6rrd c Commonwealth of Massachusetts .� Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 163 Percival Drive Property Address Jim Macurdy Owner Owner's Name information is required for every West Barnstable MA 02668 8-5-19 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 f Yl EAR 0 0 tSinsp.doc-rev.712812018 Title 5 Offidal Inspection Form:Subsurface Sewage Disposal System Page 15 of 18 g I• abed xe� dH ££:LO 61.0Z 60 5nV Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,J 163 Percival Drive Property Address Jim Macurd Owner Owner's Name information is West Barnstable MA 02668 8-5-19 required for every State Zip Code Date of Inspection page. City/Town D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells )va 14' 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: 5-8-87Date ❑ 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: Bottom of Chambers at 6' below grade Bottom of Chamber's at 8'above T.H. Depth. Before filing this Inspection Report,please see Report Completeness Checklist on next page. I l5insp.doc-rev 7i 2812018 Title S 0fAdal Inspection Form:Subsurface Sewage O'mpmal System-Pege 17 of 18 ` L6 abed xed dH ££:LO 660Z 60 6rnd Commonwealth of Massachusetts tTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 163 Percival Drive Property Address Jim Macurdy Owner Owners Name information is required for every West Barnstable MA 02668 8-5-19 page. City/Town State Zip Code Date Di Inspection E. Report Completeness Checklist Complete all applicable sections of this form Inclusive of: ® A. Inspector Information:Complete all fields in this section. ® B.Certification: Signed &Dated and 1, 2,3, or 4 checked ® 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 o a Jr. C HAM A°5 g N� �w t5in9p.doc rev.7i2612018 TO 5 Oflldel Inspection Form:Subsurface Sewage Disposal System•Page 18 0113 91, a5ed xeJ dH ££10 61,0Z 60 5rfV TOWN OF BARNSTABLE LOCATION 1 / ,mil 10— SEWAGE # ZQC)a-02 VILLAGE/_�� `7�rr'%Gc�/.)1 ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO.(S'0,H SEPTIC TANK �APACFFY 1 S.D:] LEACHING FACILITY: (type) (size) S:O NO.OF BEDROOMS BUILDER OR OWNE PERMFFDATE: COMPLIANCE DATE: s &3 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site.or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by l ry fJ ft 11 rnrn P9 F4 09, O e TOWN OF BARNSTABLE A I Oa 01� M O-. 1 p 6C:ATION l`it1. SEWAGE # 20a3-a2 7 i rLLAGE fdL3 ` 2z::L-14-a/•b ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. J-- SEPTIC TANK CAPACITY 131.0-0 / LEACHING FACILITY: (type) r/�/7a'!py (size) S`o--(D NO. OF BEDROOMS BUILDER OR OWNE PERMITDATE: 7 COMPLIANCE DATE: Z Q� 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 wetland's exist within 300 feet of leaching facility) Feet Furnished by =.39' =5-z, . - I j jr No\f00, �`� + Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 01ppYitation for 30igpogaf *potem Con6truction permit Application for a Permit to Construct( )Repair( )Upgrade( k)Abandon( ) El Complete System 21 Individual Components Location Address or Lot No. j Owner's Name,Address and Tel.No. j'� W`V/� C' I lq 1 pif r� Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. ��Is�; &Wn caoe, ���eer/5p / 3 jo�z Type of Building: Dwelling No.of Bedrooms Lot Size 1 sq.ft. Garbage Grinder Other Type of Building 2��41.e No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow l gallons per day. Calculated daily flow 7 7 gallons. Plan Date Z A? 3 Number of sheets Revision Date Title 19 lle�3 Size of Septic Tank / ® lrv4' ? � y9 Type of S.A.S. Description of Soil 33 1 v3,(�Z 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 Certifi- cate of Compliance has been issued b is, o f ealth. Signed Date I�ZZ o;3 Application Approved by Date Application Disapproved for the following reasons Permit No. Date Issued :_/ .. _., .:� �._,wisy+�+�,n"Y:._ 'i.i.ffi.+�Yf1F.y::fOSY.. .+w.4r.• .._....w_...... .� r .. n w. c t No. / V — - Fee ` THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 2ppr cation for 35iopotaf 4pgtem Construction Permit %Application for a Permit to Construct( )Repair( )'Upgrade( V)Abandon( ) ElComplete System 1E Individual Components Location Address or Lot No. / Owner's Name,Address and Tel.No. ,0/', Oif�Q/��I Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 411 �Op�?� •,1f j'C'D�fS.�; ,�Gv�1 C��O� �:�y����r-�yy, Type of Building: Dwelling No.of Bedrooms Lot Size . 29E sq.ft. Garbage Grinder Other Type of Building 5%// lc No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow `7 o gallons. Plan Date / /D / 3 Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. 3` Description of Soil (' Nature of Repairs or Alterations(Answer when applicable) �/)`�P ��?/ 70. ��� Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issue �is,9oard)ofjjealth._ / Signed Y/ Date 1l2'Zl3 Application Approved by Date Application Disapproved for the following reasons Permit No�✓ �`'J� Date Issued —————————————————————————————————------ THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of QComphance THIS IS TO CERTIFY, that t e On-site Sey-Age Disposal System Constructed( )Repaired(Upgraded( 4!) Abandoned( )by O' �`G, ` '�l�S at /h.-3 Z21, has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. ZOO 3—039 dated Z 3/Q 3 Installer Designer n The issuance o this ermit shall not be construed as a guarantee that the syste �/� nct"on s designed. Date 2. .� o_ Inspector No. i----„—� -------------------------Fee 7 3 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE} MASSACHUSETTS Diopool *pztem Construction Permit Permission is hereby granted to C nstruct( )Re air( )Upgrade(e/) bandon( ) System located at m_3 ! / C�r/� !C//" and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Construction must bJcompl ted within three years of the date of this Date: Approved b ' PP Y CERTIFICATE OF ANALYSIS Page: 1 Barnstable County Health Laboratory Report Prepared For: Report Dated: 11/12/2002 0e Order Number: -�G,021 e James Macurdy P O Box 203 Centerville, MA 02632 o�OTr�6 lF Laboratory ID#: 0218089-01 Description: Water-Drinking Water Sample#: 18089 Sampline Location: 163 Percival Drive,West Barnstable Collected: 11/07/2002 Collected by: James Macur Received: 11/07/2002 Routine ITEM RESULT UNITS MCL Method# Tested LAB: IC Lab Nitrates <0.1 mg/L 10 EPA300.0 11/08/2002 LAB: Metals Copper 0.1 mg/L 1.3 SM 3111B 11/12/2002 Iron <0.1 mg/L 0.3 SM 3 111 B ... 11/12/2002 ... .. Sodium 9 mg/L 20 SM 3111B 11/12/2002 LAB: Microbiology Total Coliform Absent P/A Absent 309 11/07/2002 LAB: Physical Chemistry Conductance 110 umohs/cm EPA 120.1 11/07/2002 pH 6,4 pH-units EPA 150.1 11/07/2002 Note: Water sample meets the recommended limits for drinking water of all above tested parameters. Approved By: (Lab Director) t t - Superior Court House, PO.Box 427, Barnstable, MA 02630 Ph: 508-375-6605 A$7,v /�7TOWNP( STABLE CATION + J: 1 ?ef,L:,V PA IZ P, SEWAGE # VILLAGE W " �cnlsab�Q- _ASSESSOR'S MAP&LOT I/D INSTALLER'S NAME&PHONE NO. ��e�d � Lo ASV • SEPTIC TANK CAPACITY . /<6 O JA\ r- LEACHING FACILITY: (type) (size) �0 i NO.OF BEDROOMS } I BUILDER OR OWNER PERMITDATE: -`a.�i���� COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by ,oq- qd No................� 64d • Fps........ .................. THE COMMONWEALTH OF MASSACHUSETTSr BOARD OF HEALTH TOWN OF BARNSTABLE Appliratiutt for Di-iripw3al Work Tomitrudiurt rami# Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: 14 --....... ..�- i..ns�...... .. ..... ___--------••--•--------- ----------------------------------------------------------------- �4ocation-Address No, _...................�-. t^���5 �'-P-C-�......----- -`'..o-'---------------------+ - t .!�4 � Il-A . . T`� Owner \ Address W b'�f, G S� k c�N `l(� ��rn+�€1� --;>--- '�-- �Z' S I 1 � a ............................................................�------------------•--........-- Installer Address U Type of Building Size Lot__7�!!a, 5.1....Sq. feet ..� Dwelling—No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons..........._................. Showers ( ) — Cafeteria ( ) Other fixtures ----------------••-------------•--------•- ......................... W Design Flow......_.._�_�.�..........................gallons per person per day. Total daily flow-------------.5... .......................gallons. WSeptic Tank—Liquid capacity.1SoQ..gallons Length................ Width---------------- Diameter_............. Depth................ x Disposal Trench—No. .................... Width..... t----------- Total Length___- ......... Total leaching area.y I !�i __sq Seepage Pit No---- _. .___ Diameter......!.U-__..... Depth below inlet...ft............. Total leaching area`I-£b(ajL)�U__ . Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed }................ Date........ Test Pit No. I... ___minutes per inch Depth of Test Pit._.1.�4".._.1. Depth to ground water-----t� �?-..--- rS. Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a •-•••-•......................•-•-----..........---•----•-•-•--------•-••-----------------...__------••. ._•---------..._...----.....----- 0 Description of Soil_. � - �� �P' SyL3 � -- / °��- /��_E.__5!.*["�._.v? . j_ 11<T}-4--....-•-•- ................. W ------------------------- -------------------------------------------------------------------------------------------- --------------------------------------------------------------•--------•--_..._. V Nature of Repairs or Alterations—Answer when applicable............................._.___.___.____..........__.________..._............................ _•----•--------•-•----•---•-------------------•----••--•--•--•--••------•-......---------------......_....----------------------•---••----•--•-••-------•--•-•••••••••••---•-•-•._...._......---••--•--- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the y p p s ue system In operation until a Certificate of Com lI has be the oard ealth.I o Sign --- ------------------------- -��. ..j`. .% Application Approved B - --------------- --------- Date Application Disapproved for the following reasons: . ............ ........ ................................. ....................... ....t e.................. --------------------------------------------------------------------- ------------- n� Date Permit No. �.-----7--`-�I--------------------------- Issued .--..-- ..l am Date - a . - No 9s�... / - Fps...._.../ v...... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliration for DiopoiiMl lVnrka Tonotrur#"tun VPrntit Application is hereby made for a Permit to Construct ( /) or Repair ( ) an Individual Sewage Disposal, System at: .... --------------------------••••-•--•• -----• --- -•-•••---- -•-----••-•---...-•--•- 1 Location-Address o Lot No. ...................... .T (-.........e..._ L. �(......�-•.....��s, --��4 . e� ----------------------- - Owner — Address W �r-3_Z7U�-.C_y_i T t ���ST��I,���i ur-� 7(a5 !: %: 1����t IS .�I l 4 c� ... Installer Address Type of Building S Size Lot_.35_, 5 ....Sq. feet t., Dwelling—No. of Bedrooms................____________________________Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) dOther fixtures ------------------------------- ------------------------------------------...--------------eJ-�-�-----------•---------...--------- W DesignFlow______________�_. . . _ i�Q gallons per person per day. Total daily flow Depth`._gallons. 9 Septic Tank—Liquid capacity_____-_v.galIons Length---------------- Width_. g P P P Y Y W Disposal Trench—No_ ____________________ Width......G.l----------- Total Length-.-_Lc__._._._.__ Total leaching Seepage Pit No----L.4,..Z-^---- Diameter------1_U.1...... Depth below inlet_._`1..t........... Total leaching areal (n_5��12_.s_q t. Z Other Distribution box ( ) Dosing tank ( ) '" Percolation Test Results Performed by i �,b_.a-.!�I���•-ra -f:iz• - :1�,•__-- :Z_ Cam•-•-•••--_. a ------------ Date------ a Test Pit No. I.X.-Z-._.-minutes per inch Depth of Test Pit_-1�_�_':...... Depth to ground water.....U 1�..._.. f= Test Pit No. 2................minutes per inch Depth of Test Pit--------_........... Depth to ground water........................ D Description of Soil._.4�.._ ........ T--Sty�350�c�__ :.C?U.___.__�+1\I .._ t]_�l ._.!�? �]Z t'� 1-4____________________________ --•-- --•-•----------•--•-------••---•••-----••------•-•--•------•-••-••......•--•.._........•_•••--- W UNature of Repairs or Alterations—Answer when applicable------------------------------------------------------------------------------------------------ ........................................................................................................................................................................................................ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has beeenissued-by the board of health. cf -, f.... �-y� ........... ...................--� f�/... :. .. _ f f Application Approved BY - a....f....`.., .......... .� .�. t .. —S_... ..... .. ................ ..- .- - .... Date Application Disapproved for the following reasons: .................................... .. ... ..... ......................... -- .......................... ...... ............ . ............................. . .................................. q �, � Date Permit No. / 5- ..�-;.I........................... Issued ........-•�....i.��..-...;_S_................ Dace THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE T&er#tftrtt#E of C11ontyliance THIS IS TO CERTIFY, That the Individual ividual Sewage Disposal System constructed ( or Repaired ( ) b r .. /©:�c�t w o.---..... �✓LS. /"Cc<: Cam= �-.��C.' ..._--------------------------------------------- � � ----•- mstauer _ 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. 19,E—7.P.1--------------_.. dated ---3..'.-)J.._-....9 _57_.. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE-----------------------I. .�—..YZ---- ---..�- ................... Inspector .............................................. - THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH gs� 72� TOWN OF BARNSTABLE FEE j.................. Diupnpal Workii Tomitrur#ion rrutit Permission is hereby granted_..CSC.'' y't ` r-:a• /iy - /r-='... .. / ........................................... to Construct ( /)for Repair ( ) an Individual Sewage Disposal System Street �' S - 7�/ as shown on the application for Disposal Works Construction Per It No._._..__f..._.._. Dated.;:.:-�_'...... / Board of HealtV DATE '" .. . -'------••-•-••-•------•-•--- / � 7 FORM 36508 HOBBS&WARREN,INC..PUBLISHERS ` - ENVIROTECH LABORATORIES, INC. MA Cert. No.: M-MA 063 449 Rte. 130 - Sandwich,MA 02563 (508)888-6460 - 1-800-339-6460 FAX(508)888-6446 CLIENT: Reef Realty LOCATION: Lot 31 Percival Dr. P.O. Box 186 W. Barnstable, MA W. Dennis, MA 02670 SAMPLE DATE: 3-20-95 COLLECTED BY: Clifford Well Drilling DATE RECEIVED: 3-20-95 TIME: 4:OOPM LAB I.D. NO. : E3-270 JOB TYPE: New well SAMPLE I.D.NO. 31 WELL SPECS.: 72, RESULTS OF ANALYSIS: Parameters Units Recommended Limit Result Coliform bacteria/100m1 (MF Method) 0 0 pH pH units 6.0-8.5 6.59 Conductance umhos/cm 500 108 Sodium mg/L 28.0 8.73 Nitrate-N mg/L 10.0 0.06 Iron mg/L 0.3 0.24 Manganese mg/L 0.05 0.008 Volatile Organics See enclosed report. EPA 601/602 ug/L Yes No WATER IS SUITABLE FOR DRINKIN SE FOR PARAMETERS TESTED. XXX Date Ronald Saari Laborat Director LT = Less Than GROUNDWATER ANALYTICAL EPA METHODS 601 and 602 Volatile Organics (GC/PID/ELCD) Field ID• E3-270 Lab ID: 10221-01 Project: Reef Realty/Lot 31 Percival Batch ID: V62-0577-W Client: Envirotech Sampled: 03-20-95 Cont/Prsv: 40mL VOA Vial/HC1 Cool Received: 03-21-95 Matrix: Aqueous Analyzed: 03-22-96 PARAMETER CONCENTRATION REPORTING LIMIT (u5/L) (ug/L) Dichlorodifluoromethane BRL 5 Chloromethane BRL 5 Vinyl Chloride BRL 5 Bromomethane BRL 5 Chloroethane BRL 1 Trichlorofluoromethane BRL 1,1-Dichloroethene BRL 1 Methylene Chloride BRL 1 'trans-1,2-Dichloroethene BRL 1 1,1-Dichloroethane BRL 1 cis-1,2-Dichloroethene * BRL 1 Chloroform 2 1 1,1,1-Trichloroethane BRL 1 Carbon Tetrachloride BRL 1 Benzene BRL 1 1,2-Dichloroethane BRL 1 Trichloroethene BRL 1 1,2-Dichloropropene BRL 1 Bromodichloromethane BRL 1 2-Chloroethyl Vinyl Ether BRL 5 BRL 1 cis-1,3-Dichloropropene BRL I Toluene BRL 1 trans-1,3-Dichloropropene 1,1,2-Trichloroethane BRL 1 Tetrachloroethene BRL 1 Dibromochloromethane BRL 1 Chlorobenzene BRL 1 Ethylbenzene BRL 1 meta-and Para-Xylene * BRL 1 ortho-Xylene * BRL 1 Bromoform BRL 1 1 1,2,2-Tetrachloroethane BRL 1 1,3-Dichlorobenzene BRL 1 1,4-Dichlorobenzene BRL 1 1,2-Dichlorobenzene BRL 1 QC SURROGATE COMPOUND SPIKED MEASURED RECOVERY QC LIMITS a,a,a-Trifluorotoluene 30 30 100 % 87 - 113 % 1,2-Dichloroethane-d4 30 32 108 % 83 - 117 % BRL = Below Reporting Limit. * Non-target compound. Method References: Method 601 - Purgeable Halocarbons and Method 602 - Purgeable Aromatics, 40 C.F.R. 136, Appendix A (1986). �� 1 ©© / -_- _ __------- No.- --F-�_•__Ij � Fee- -6� BOARD OF HEALTH TOWN OF BARNSTABLE CJ ApplicationArlVell Cootruction Permit Ap lica 'on heFeby ade fq(a permit to Construct A, Alter ( ), or Repair ( )an individual Well at: - / -----------------------� �eWc ---------------------- ------- Location Address Assessors Map and Parcel l�C_fPrPG -------------------------- - -���C. -�!�"s- ---- caner Address ------------------�- ----------------------------------- �'°�3-oJS 3° - - =0 old Installer — Driller Address Type of Building Dwelling3�&--r ----------------------------------------- Other - Type of Building ------ No. of Persons------------------------------------------ Type of Well- -- -- - - ----- -- - Capacity-------------------- - -___ - - --— Purpose of Well---- _ }1���---------------------------- 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 Certificat o is ce has been issued by the Board of Health. Signed — - - - - - ------- - �G ----- date Application Approved By— -— — -- - -- -— - � - -— —— date Application Disapproved for the following reasons:---------------------------------------------------------------------------------- ------------------------------------------------------------------------ -------------------------------------------------------- ---- date Permit No. ----- Issued----------------------------------------- -- ------------ date BOARD OF HEALTH TOWN OF BARNSTABLE (Certificate ®f (Compliance THIS IS TO CERTIFY, That the Individual Well Constructed ( ), Altered ( ), or Repaired ( ) by------------------cv c - � ------------I---nsta----ller-------------------------------------------------------------------- - -—- at---------A 1-- �t�heprovisions ----�" ` ----- -- ------------------------------------------------- Ice wit of the Town of Barnstable Board of Health Private Well Protection Regulation as described in the application for Well Construction Permit No. W t--45:-----Dated THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. --- -- DATE----------------- Inspector --------- �—_ I�--�-- --�- ------ -- - - --- r tamer, g�- Jr, 1/0��- �""K.�,u.61`�.r�`rr.�d/'.J"�¢t'+k'�iYsF{�.�.,,�•'�°`'W+7�Wtr+r" �''i>! _sAlle —0/ No -- -- -.�---15 '. P Fee----D.1-5--------- BOARD OF HEALTH TOWN OF BARNSTABLE Rp'licationArVelr Cootruction Permit Ap licata'on`�he;eby ade f9r,a permit to Construct (A, Alter ( ), or Repair ( )an individual Well at: Location — Address ses'sors Map and Par del ner t Address ------ ---f ------------------------------------- Installer — Driller Address r Type of Building Dwelling -------------------- Other - Type of Building ---------------- No. of Persons---------------------------------------- Type of Well------- -------��-------------- ------ ------------------ Capacity Purpose of Well � ' �D��'=' - -- --- 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 .o o is ce has been issued by the Board of Health. i -� � Signed ---- - --- ------ - - ----------- - --------- y ------- ---- date D 1 Application Approved By- - - �-------------- --- --�='1 - - ---—— date Application Disapproved for the following reasons:—---—-------------------------------------------------------------------------------- -----------—-- - - -----------_-------- ------------------- --------------- ------------------------------------------------ date 'Permit No. -- -- --- — -- Issued------------------------------------------- - -------------- date ss�®mtw ss..s a�w mass-.� ry e�sa.anew-es.s�s ss.�ar.r.�a.ru.�.oss.suss aso��aieisw.ssa'..mas�.asr ass.sss sass assr�aaeln+rw w.acaam�asr a..ar oe�.ac arcs mars.uia�sa.awc ti BOARD OF HEALTH — _ ' TOWN OF -ffARN-'STkBLE- Certificate Of Compliance THIS IS TO CERTIFY, That the Individual Well Constructed ( ), Altered ( ), or Repaired ( ) bY----------------�� ! -` -�_v --- --- --------------------------------------------------------- ------------------- �.a Installer (� at---------- --� - --- '�„�►t- -'--�-3�--w--------- l ------------------------------------------ has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection 11K1Regulation as described in the application for Well Construction Permit No. Yx- =--� �--- Dated=--��"" THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE------------------ =" f --_ - -- Inspector--- -- -- --- �..... BOARD OF HEALTH TOWN OF BARNSTABLE VrIl Cootruct ion Permit No. - - -_ Fee--- —--- Permission is hereby granted---- ---------— =—---—------------ ---------------------------- --to Construct (,"Alter ( ), or Repair ( ) an Individual Well at: No. - - - --- ---— ------------ ----------------------------------------------------------------------------------------------------------- Street as shown on thee,application for a Well Construction Permit No.- - -� 5-_- --- ---------—--- - Dated---3- ------------------------------------------- - — - � --------------------------------------- �. ,,Board of Health DATE---- Q= -------— - �t y I i NCB I � r SIT 0 i �I i I i N . ASSESSORS MAP. 110 PROPOSED WELL TEST HOLE LOGS NOTES: PARCEL, 1-12 (153'TO LEACH PIT) (1 2' TO ABUTTING c I. VERTICAL DATUM:: ASSUMED FROI! U ,Q LEA RING AREA) QUAD GVD'+,( ,) : ENGINEER. DOYLE ENGINEERING �� CURRENT ZONING RF 2. MUNICAPAL WATER IS ND?' AVAILABLE. , BUILDING SETBACKS: �y UTILITY WITNESS: JERRY DUNNING 3. SCHEDULE 40 - 4" PVC PIPE TO BE USED THROUGHOUT SEPTIC`SYSTEM. '� cLUSTaR BIB F: 30' S: 15' R: 15' > DATE 5-8-87 4. ALL PRECAST UNITS TO CONFORM WITH AASHTO PERCOLATION RATE: < 2 MIN IN H-10 & H-20 ` y� �� �s 1 •� LOADING SPECIFICATIONS. FLOOD ZONE: C 'o 1 1 H-1 -2 - 5. PE PITCH " E ss' EDGE of PAVE T TH TH 3 PI I H 1f4 PER .FOOT ,(UNLESS NOTED OTHERWISE). �,�, �, �, ► 1 64• 66.0 64D 60D 6. FIRST 2' OF PIPE OUT OF D-BOX TO BE LAID LEVEL. r 6> 8 9 i \ \ ♦ TOP dF ELEV TOP g ELEV TOP ELEV TP &SUBSOIL SUBSOIL TOP &SUBSOIL 7. THE SEPTIC SYSTEM HAS NOT BEEN DESIGNED TO ACCOMODATE THE I 1 t i \ se .0 36" 61.0 36" 57.0 Locus 1 r t i BXWIDAPX AT s3 USE OF A GARBAGE DISPOSAL. •P� r 1 ' I 1 I t , 1 ELEV. BASIN 4e CLAY 62.0 54` CL' Ss.S 54" CLAY 55.5 8. ALL CONSTRUCTION DETAILS ARE TO BE IN CONFORMANCE WITH THE ELEV. 7s.7 CLAYEY SILTY SILTY STATE OF MASS. ENVIRONMENTAL CODE (TITLE FIVE) AND LOCAL 1 1 1 1 0 LOCATION MAP , ► ► ► c SAND SAND SAND HEALTH REGULATIONS. I ► i - LOT '31 WITH WITH WITH, , 1 . \, b BWLDSRs COBBLES COBBLES 1s2' s5.o 1s2' Ss.o 1s2' 4s.o 9. CONTRACTOR TO VERIFY LOCATIONS OF ALL. UTILITIES PRIOR 35,097 f S.F. PROPOSED LEACHING ! t t '� 0.81 + AC. AREA (LOT 32) COARSE- MEDIUM MEDIUM TO CONSTRUCTION. MEDIUM -COARSE -COARSE SAND SAND SAND 10. PROPOSED SEPTIC SYSTEM LOCATION IS IN ACCORDANCE WITH MASTER \� WITH PLAN ON FILE WITH BARNSTABLE HEALTH DEPT. PROPOSED WELL GRAVEL 52.0 168" 50.0 168" 46,o LOCATION HAS BEEN REVISED FROM MASTER PLAN BUT STILL MEETS ALL SETBACK REQUIREMENTS. / \ 11. DESIGN ENGINEER TO INSPECT AND CERTIFY SUITABLE SOIL CONDITIONS NO GROUNDWATER ENCOUNTERED 1 / 69 .1 1 1 + \ \ �e d TO A DEPTH OF 4 BELOW LEACH PIT AT TIME OF CONSTRUCTION. ��, •?per 1 / / � I c0 ► \ \ , , �� I SEPTIC SYSTEM DESIGN N19 _ J ' + \ \ \ FLOW ESTIMATE: ��o c c ��'I + 1 I • \ \ -5- BEDROOMS AT 110 GAL DAY BEDROOM = 50 GAL/DAY WALK-OUT ` \ i ► \ SEPTIC TANK: sa DECK 550,GAL/DAY * L5 DAYS = 825 GAL \ s ,�:. _.,. r. •r.• I I + USE1500 GALLON SEPTIC TANK PROPOSED 24' S BEDROOM \ \ I J ( t l PROPOSED WELL DWELLING 28+ LOT 30 LEACHING AREA: GARAGE (155' TO LEACH PIT) \ USE TWO LEACH PITS (6 x 49 WITH 2 OF STONE ss' (AY EFFECTIVE DIAMETER x 4 DEEP) PROPOSED DWELLING SIDE .AREA: 10 x 4 x PI = 126 SF (2.5) = 314 GAL/DAY o BOTTOM AREA: 5 x 5 x PI =78 SF (1.0) = 78 GAL/DAY sg \ \ ♦ \ t , \ \ \ - m {�n a 4f TTY A n r +T 4rtr = B' PREVIOUS LOCATION OF x 2 PITS 786 GAL DA \ \ \ \ \ \ \ \ \ \ PROPOSED WELL. (SEE NEW LOCATION FRONT OF LOT) 57 • \ \ \ \ \ , \ , \ , 2 (NEW LOCATION DOES NOT SEP1 1 C SYSTEM SECTION 2" 1°EASTONE ItPLANT LAY OUT OF MASTER s6 \ \ \ \ 1 TH-2 \ \ \ ` \ \ �� \ \ \ \ \ \ \ \ COVERS WITHIN 12" OF3 4" - 1 1 2- � , \ \ \ I \ \ \ ` �0 73.0 OF FINISHED GRADE WASHED STONE It 1 \ \ \ \ 69 \ \ ` \ TOP OF FOUNDATION It 0cp ff� F::::l/ \ ♦ \ I \ It \ \ ` \ �+ \ 6> O O \ \ \ \ \ \ 63.39 n s \ \ \ It s 4 _ n s \ s 63.64 ELEV. D-BOX \ \ � � ,, ► \ � 1500 GAL 62.72 ELEV. 60 \ 1 I SEPTIC TANK 62.89 ` ELEV. LA 51.0 \ \ \ \ I I s� .-: 4. ..ELEV. \ � ELEV. � ,� \ ` \ ► 1 I 1 TEE SIZES: 55.0 2 :INLET: 6" UP, 10" DOWN ELEV. 10' F \ t I I I ELEV. i I I OUTLET. 6" UP, 19" DOWN TWO LEACH PITS (6 x 4) WITH 2' OF STONE (10' EFF. DIAM. x 4' DEEP) (H--20) I I I 1 I i 1 I I I 1 6,q 0 1 1 I i I SITE AND SEWAGE .FLAN 1 + KEY: L 0CA TION 1 ' + EXISTING CONTOUR: r ;,-,4-444 L , 6 PROPOSED CONTOUR: .............................. ,. 47s y LOT 31 PERCIVAL DRIVE _ s + EXISTING SPOT ELEVATION. ,25.5 WE E MA s s WEST BARNSTABL .� 8 PROPOSED SPOT ELEVATION. 25 � .�., , .•. fit; �� P1.,. 15�.9 � s PREPARED FOR: y V e TEST HOLE: UTILITY POLE. -O- REEF REALTY FENCE LINE: a DEMAREST-McLELLAN ENGINEERING ! SCALE: r = 30' DATE: 3-7-95 HYDRANT: -� !r 24 SCHOOL'STREET P.O. BOX 463 RETAINING WALL: WEST DENNIS, MASSACHUSETTS 02670 --- REFERENCE: PLAN BOOK 413 RAGE 99 DM # B4 $=3f T HOMAS McLELLAN, P.E. JOHN Z. DEMAREST JR., P.L.S. ' � i 1 / N ASSESSORS MAP: 110 PARCEL 1-1z PROPOSED WELL TEST HOLE LOGS NOTES: (193' TO LEACH PIT) f(152' TO ABUTTING - LEACHING AREA) 1. VERTICAL DATUM. ASSUMED FROM QUAD (NGVD CURRENT ZONING: RF ENGINEER: DOYLE ENGINEERING 2, MUNICAPAL WATER IS NOT AVAILABLE. �� / a' BUILDING SETBACKS: y UTILITY WITNESS: JERRY DUNNING CLUSTER 3. SCHEDULE 40 - 4" PVC PIPE TO BE USED THROUGHOUT SEPTIC SYSTEM. h'f F: S: - R: 15' DATE: 5-8-67 -�� _.1 yy 4. ALL PRECAST UNITS TO CONFORM WITH AASHTO H-10 & H-20 PERCOLATION RATE: < 2 MINI IN LOADING SPECIFICATIONS. FLOOD ZONE: C yo 1 ►99 EDGE OF PAVE y ► ► TH-1 TH-2 TH-3 5. PIPE PITCH = 4" PER FOOT,(UNLESS NOTED OTHERWISE). ► 164- 66.0 64.0 60A� .. 5 sc � s9 \ 6. FIRST 2' OF PIPE OUT OF D-BOX TO BE..LAID LEVEL. TOP & ELEV TOP & ELEV TOP & ELEV c a.1. , ► ► r r , ' I ► ` SUBSOIL SUBSOIL SUBSOIL 7. THE SEPTIC SYSTEM HAS NOT BEEN DESIGNED TO ACCOMODATE THE z Lis ' r , ' ► ` � AT 3r 63.0 3C 6 ss" 57D USE OF A GARBAGE DISPOSAL. CATCH BASIN ELEv. ffi 7s.7 •�" CLAY sz.o 54' cam' s9.5 s4" cam' Sys 8. ALL CONSTRUCTION DETAILS ARE TO BE IN CONFORMANCE WITH THE I i ► o ® CLAYEY SILTY SILTY STATE OF MASS. ENVIRONMENTAL CODE (TITLE FIVE) AND LOCAL LOCATION MAP , r I , SAND SAND SAND HEALTH REGULATIONS. LOT 31 ► ► ► WITH WITH WITH 35,09�' f S.F. ' ► ' r ► 132- BWLDaM 55.0 132- COBBLES 53.0 13,r COBBLES 49.0 9. CONTRACTOR TO VERIFY LOCATIONS OF ALL UTILITIES PRIOR PROPOSED LEACHING i ► ► I ► I ' i y� ,� (0.81 AC.) AREA (LOT 32) 1 ► a• ' COARSE- MEDIUM MEDIUM TO CONSTRUCTION. ' r ► MEDIUM -COARSE -COARSE SAND SAND SAND 10. PROPOSED SEPTIC SYSTEM LOCATION IS IN ACCORDANCE WITH MASTER � I� i i i ► I ag• � y�, a � �? � WITH PLAN ON FILE WITH BARNSTABLE HEALTH DEPT. PROPOSED WELL � I ' ' i ► GRAVEL sc I \ °Z m sz.o 1ss" soo 1s8' ,�•0 LOCATION HAS BEEN REVISED FROM MASTER PLAN BUT STILL MEETS ALL / , r ► I I ` a � SETBACK REQUIREMENTS. ' ' r ► ► I ' `m 11. DESIGN ENGINEER TO INSPECT AND CERTIFY SUITABLE SOIL CONDITIONS \ NO GROUNDWATER ENCOUNTERED TO A DEPTH. OF 4' BELOW LEACH PIT AT TIME OF CONSTRUCTION. s i• i SEPTIC SYSTEM DESIGN 0.0 s � . ti° ► ► �.y�j�Gb� c yes •� \ \ FLOW ESTIMATE: - + o I I ► \ BEDROOMS AT 110 G AL/DAY/BEDROOM - 550 GAL/DAY WALK-OUT ► � -9c y \ ►� �\ I ' I '� ' i y� SEPTIC TANK: sa DECK ::�. i , • ' y� 550 GAL/DAY * 1.5 DAYS = 825 GAL s• f,I,: r• , USE 1500 GALLON SEPTIC TANK PROPOSED 24' 5 BEDROOM \ � ` � i I .•'.► �'•. i •.•I r I PROPOSED WELL GARAGE DWELLING 28' i I I ► I LOT 30 LEACHING AREA: ` 1 i 1 I ► I (155' TO LEACH PIT) s� s� \ \ `\ `\ �\ \ ' ► ` USE TWO LEACH PITS (6' x 4") WITH 2' OF STONE 24' 36, (10' EFFECTIVE DIAMETER x 4' DEEP) e � � ` ��,�\ `` `\ \ � `` `\ `\ ` � PROPOSED DWELLING SIDE AREA: 10 x 4 x PI = 126 SF (2.5) = 314 GAL/DAY - co ` \ ` ` \ BOTTOM AREA: 5 x 5 x PI = 78 SF (1.0) =1 78 GAL/DAY s9 ` � � � ` to 1 .� � � \ � ` ` T� � .. ` \ \ \ . TOTAL CAPACITY GAL/DAY ti' `�• __ _ -. --- 6�9 PREVIOUS LOCATION OF x 2 PITS 786 GAL/DAY a ` \ ` PROPOSED WELL. (SEE NEW LOCATION FRONT OF LOT) (N� oUDESNOTSEPTIC SYSTEM SECTION AT z" PEASTONE ' TH-2 ` � � ` \ \ � PLAN). OF 34" - 1 COVERS WITHIN 12" / 1/2" 3\ j \ \ ` \ \6,9 1� 73.0 OF FINISHED GRADE TH- WASHED STONE TOP OF FOUNDATION ss \ I I \ \ \ es \ 6& \ I \ \ �63.39 4' o0 63.64 15001 GAL ELEV. D-BOX 62.72 \ ` \ ` ` ► I i ELEV. SEPTIC TANK 62.89 ELEV. 9 51.0 ELEV. ELEV.` t TEE SIZES: 55.0 z, s 2 INLET: 6" IUP, 10" DOWN ELEV. '--- 10' ELEV. ► r I ► , OUTLET 6'" UP, 19' DOWN TWO LEACH PITS (6' x 4') WITH I 2' OF STONE (10' EFF. DIAM. x 4' DEEP) (H-20) � I I I I i i a ► I I I � ' 1 1 i o � , SITE AND SEWAGE PLAN 1 ► ► 1 ' I s� 1 ► ► ' I KEY: LOCATION.• r ► ' ' �► 6' EXISTING CONTOUR: , ' r <$" ' r�` `'-l��s LOT 31 PERCI V AL DRIVE ' co PROPOSED CONTOUR: .............................• 1 EXISTING SPOT ELEVATION 25.5 jj �� ,t__ x_�. �` ; i " , - _ `,r, WEST BARNS'TABLE, MA sc PROPOSED SPOT ELEVATION:F25 s9 PREPARED FOR v TEST HOLE: UTILITY POLE: -0- FENCE LINE: r REEF REALTY DEMAREST-McLELLAN ENGINEERING HYDRANT: -�- I�, {� �`�'^'" � `' SCALE: 1" = 30' DATE: 3-7-95 RETAINING WALL: 24 SCHOOL STREET P.O. BOX 463 !! U WEST DENNIS, MASSACHUSETTS 02670 REFERENCE: PLAN BOOK 413 PAGE 99 ; DM # .54---=--31 T HOMAS MCLELLAN, P.E. JOHN Z. DEMAREST JR., P.L.S. i I SYSTEM PROFILE TEST HOLE LOGS ACCESS COVER TO WITHIN 6" OF FIN. GRADE (NOT TO SCALE) '7DOYLE ENGINEERING ACCESS COVER (WATERTIGHT) TO H, , STREET ET MINIMUM .75' OF COVER OVER PRECAST F A WITHIN 6 0 FIN. GRADE 2% SLOPE REQUIRED OVER SYSTEM 66.0' JERRY DUNNING WITNESS: �y 2" DOUBLE WASHED PEASTONE 5 8 /87 EL 65.0 RUN PIPE LEVEL DATE:- / l FOR FIRST 2' 1500 r _\ 3 MAX PERC. RATE - < 2 M!N/iNCH aEr:avqL Da. EXISTING �l \ GALLON SEPTIC t 63.0' 63.6'* CLASS _ SOILS P# TANK (H 10 ) GAS 62.28' (RE-USE) BAFFLE r oogo C7 m o 0 0 0 0° ,� 62.45 62.17' 0 0 0 0 0 0 0 0 i �' 4' AROUND 6" CRUSHED STONE OR MECHANICAL �oQ o C7 0 o C7 © C7 Cl �� COMPACTION. (15.221 [2)) 0025� 2 0 0 0 0 0 0 0 o I' 0 60.1 7' `\l' ELEV. I� DEPTH OF FLOW 4' MIN MIN " r ' r TEE SIZES- ( 2 % SLOPE) ( 1 SLOPE) 3/4" TO 1 1/2 DOUBLE WASHED STONE 64.0 Locus lt INLET DEPTH = 1OV/1 I OUTLET DEPTH = 1 4pyyxpo LOCATION MAP NTS 36" 63.0' 36" 61.0' LEACHf���G i FOUNDATION EXIST. SEPTIC TANK 26' D' BOX -13' `f 110 - ASSESSOR MAP A 1 1 FACILIT'; S PARCEL 2 � r I, ll 10.17 48" 62.0' 54" 59.5' 7 i 0 C 0 11 / oo WELL I 50.0' N h r 6Ire132" 55.0' 132" 53.0' LOT 31 COARSE-MED. 35,097t SF MED-COARSE SAND WITH SANG Wr, t71.9S 99�5 GRAVEL d � SPACE 168„ 52.0' 168" 50.0' f DRAINAGE NOTES: EASEMENT NO WATER ENCOUNTERED 69. sow �g° - I _WELL SEPTIC DESIGN: (caRBAGE alsPosER Is INOT ALLOWED ) 1 DATUM IS ASSUMED FROM QUAD MAP / ... '.^i 'FLOW: 4 h�� 1,1 n - a, ,r,t:n,n , t„ T'['•L^ [` "'Cl EX!f"ti'tRrn _a 70.11 BENCHMARK. USF .T.OP 0 : ,;ESIGN fLO►N. BEDR.,c�tJ5 ( ,1C vPC' - 1140 GPD 2. tvt� t.t�,r,^.� .��,tER "'C FOUNDATION LOWER LEVEL 1� 1.34 USE A 440 GPD DESIGN FLOW 3. MINIMUM PIPE PITCH TO BE 1 8" PER FOOT. AT EL I. 69.5 71. _ 4. DESIGN N F - 1 0 LOA LOADING R P D 0 ALL PRECAST T UNIT T E S S O AA H H BE c _ S 0 �qpp qS SEPTIC TANK. 440 GPD ( 2 ) 8$a Rpk CiNF 5. PIPE JOINTS TO BE MADE WATERTIGHT. r � -�-i1500 _-� GALLON SEPTIC TANK (RE-USE EXISTING)89 0 � FG£o <o USE s" _ `6. CONSTRUCTION DETAILS TO BE 1N ACCORDANCE WITH MASS. 66.to LEAC' 1G ENVIRONMENTAL CODE TITLE V. 66 .44 EXISTING SIDES: 2(33.5 + 12.83) 2 (.74) = 137 7. THIS PLAN IS FOR PROPOSED SEPTIC SYSTEM ONLY AND IS NOT DWELLING CASTO BE USED FOR ANY OTHER PURPOSE. ,..».6 ,► 33.5 x' 12.83 (.74) = 318 „ 1 BOTTOM: 8. PIPE FOR SEPTIC SYSTEM TO SCH. 40-4 PVC. 72ze TOTAL: 615 S.F. 455 GPD 9. COMPONENTS NOT TO BE BACKFILLED OR CONCEALED WITHOUT DECK i t72.09 INSPECTP❑N BY BOARD OF HEALTH AND PERMISSI❑N ❑BTAINED +65. JSE (3) 500 GAL. LEACHING CHAMBERS (ACME OR 7 a3e FROM A❑ BOARD OF HEALTH, --F63.39 99 6 .75 72as I QUAL) WITH 4' STONE ALL AROUND+6 10. PUMP & REMOVE (OR .FILL W/CLEAN SAND) EXISTING LEACH. PITS +6S 71.99 66.16 4417 / EXI N ' SEPTI7fA1 o +64. 2 TANK J 5' REMOVAL OF UNSUITABLE 1 +71.28 6 .9 ' o +60.5SOIL REQUIRED AROUND 6.15 LEGEND EXIST .PERIMETER OF LEACHING DWX TITLE 5 SITE PLAN FACILITY DOWN TO SUITABLE ' SOIL LAY 23 ER. REPLACE WITH +6 6692 100.0 PROPOSED SPOT ELEVATION OF CLEAN MED. SAND. ENGINEER ((�� Z n /� \ / /� I TO INSPECT AND CERTIFY 38 b'�k66:31 163 3 f E R C I V A L DRIVE REMOVAL L64 LPIT `� L,P 6B 100x0 EXISTING SPOT ELEVATIION IN THE TOWN OF: 15s .67r TH1 6�>tg 150 PROPOSED CONTOUR ( WEST) BARNSTABLE SMSMALL .39 THE 9y 100 EXISTING CONTOUR PREPARED FOR: BORTOLOTTI CON STRUCTION/O'HEARN +62.17 +61,04 STH 1 30 0 30 60 90 ° w BOARD OF,HEALTH I cc a MA rr APPIED DATE SCALE. 1 30' JANARY 1 DATE. U 0, 2003 1 off 508-362-4541 ' fox 508 362-9880 I down cape engineering, rnc. ����N of /�,N�of f P qJ�` CIVIL ENGINEERS A�� `yG ARNEy�1 OVIL y I LAND SURVEYORSER Q a 3o�s l : 02- 4 1S 939 main st. Yarmouth, ma 02675 OJ I n P.L.S. DATE - --_ _ -