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Home My WebLink About0295 WILLOW STREET - Health 295 WILLOW- :STREET W ;�'-est Barnstable A=131-021 ; t ............. I __ TOWN OF BARNSTABLE LOCATION c � '"(M11IQW 'TT, SEWAGE# VILLAGE W• (9A[As i4�k ASSESSOR'S MAP&PARCEL INSTALLERS NAME&PHONE NO. SEPTIC TANK CAPACITY WD M LEACHING FACILITY:(type) r J NOW 7 (size) NO.OF BEDROOMS/� / OWNER OASSar PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximurif: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) J Feet FURNISHED y ' a r 3 3� ly 3 4 7a Page: 1 CERTIFICATE OF ANALYSIS I Mi Barnstable County Health Laboratory Report Dated: 4/12/2006 Report Prepared For: Sally Desmond Order No.: G0634986 Desmond Well Drilling P O Box 2783 Orleans , MA 02653 Laboratory ID th 0634986-01 Description: Water-Drinking Water Sample 9: Sampling Location 295 Willow St.West Barnstable,MA Collected: 4/10/2006 Collected by: DWD Map 131 Parcel 021 Received: 4/10/2006 Routine ITEM RESULT UNITS RL MCL Method# Tested LAB: Inorganics Nitrate as Nitrogen 0.87 mg/L 0.10 10 EPA 300.0 4/10/2006 LAB: Metals Copper BRL mg/L 0.10 1.3 SM3111B 4/10/2006 Iron BRL mg/L 0.10 0.3 SM 3111B 4/10/2006 Sodium 24. mg/L 1.0 20 SM 3111B 4Z1' 2006- LAB: _Microbiology_ Total-Coliform Absent P/A 0 0 309, < 4/10/2006 c CC' LAB: Physical Chemistry i -._ .Z( _71 k Conductance 210 umohs/cm 2.0 EPA 120.1 j 4%1.0/2006- pH 6.5 pH-units 0 EPA 150.1 �0/200F6�s EPA 524.2- Volatile Organics by GUMS ITEM RESULT UNITS RL MCL Method# Tested LAB GC/MS 1,1,1,2-Tetrachloroethane BRL ug/L 0.5 EPA 524.2 4/10/2006 1,1,1-Trichloroethane BRL ug/L 0.5 200 EPA 524.2 4/10/2006 1,1,2,2-Tetrachloroethane BRL ug/L 0.5 EPA 524.2 4/10/2006 1,1,2-Trichloroethane BRL ug/L 0.5 5.0 EPA 524.2 4/10/2006 1,1-Dichloroethane BRL ug/L 0.5 EPA'524.2 4/10/2006: j1 Dichloroethene BRL ug/L 0.5 7.0 EPA 524.2 4/10/2006 1,1-Dichloropropene BRL ug/L 0.5 EPA 524.2 4/10/2006 1,2,3-Trichlorobenzene BRL ug/L„ 0.5 EPA 524.2 4/10/2006 1,2,3-Trichloropropane BRL ug/L 0.5 EPA 524.2 4/10/2006 RL = Reporting Limit MCL=Maximum Contaminant Level Superior Court House, PO. Box 427, Barnstable, MA 02630 Ph: 508-375-6605 I CERTIFICATE OF ANALYSIS Page: 2 Q I' Mi Barnstable County Health Laboratory Report Dated: 4/12/2006 Report Prepared For: Sally Desmond Order No.: G0634986 Desmond Well Drilling P O Box 2783 Orleans, MA 02653 1,2,4-Trichlorobenzene BRL ug/L 0.5 70 EPA 524.2 4/10/2006 1,2',4-T rim ethylbenzene BRL ug/L 0.5 EPA 524.2 4/10/2006 1,2-Dibromo-3-chloropropa BRL ug/L 0.5 EPA 524.2 4/10/2006 1,2-Dibromoethane (EDB) BRL ug/L 0.5 EPA 524.2 4/10/2006 1,2-Dichlorobenzene BRL ug/L 0.5 600 EPA 524.2 4/10/2006 1,2-Dichloroethane BRL ug/L 0.5 5.0 EPA 524.2 4/10/2006 1,2-Dichloropropane BRL ug/L 0.5 EPA 524.2 4/10/2006 1,3,5-Trimethylbenzene BRL ug/L 0.5 EPA 524.2 4/10/2006 1,3-Dichlorobenzene BRL ug/L 0.5 EPA 524.2 4/10/2006 1,3-Dichloropropane BRL ug/L 0.5 EPA 524.2 4/10/2006 1,4-Dichlorobenzene BRL ug/L 0.5 5.0 EPA 524.2 4/10/2006 2,2-Dichloropropane BRL ug/L 0.5 EPA 524.2 4/10/2006 2-Chlorotoluene BRL ug/L 0.5 EPA 524.2 4/10/2006 4-Chlorotoluene BRL ug/L 0.5 EPA 524.2 4/10/2006 Benzene BRL ug/L 0.5 5.0 EPA 524.2 4/10/2006 Bromobenzene BRL ug/L 0.5 EPA 524.2 4/10/2006 Bromochloromethane BRL ug/L 0.5 EPA 524.2 4/10/2006 Bromodichloromethane BRL ug/L 0.5 EPA 524.2 4/10/2006 Bromoform BRL ug/L 0.5 EPA 524.2 4/10/2006 Bromomethane BRL ug/L 0.5 EPA 524.2 4/10/2006 Carbon tetrachloride BRL ug/L 0.5 5.0 EPA 524.2 4/10/2006 Chlorobenzene BRL ug/L 0.5 100 EPA 524.2 4/10/2006 Chloroethane BRL ug/L 0.5 EPA 524.2 4/10/2006 Chloroform 2.3 ug/L 0.5 80 EPA 524.2 4/10/2006 Chloromethane BRL ug/L 0.5 EPA 524.2 4/10/2006 cis-1,2-Dichloroethene BRL ug/L 0.5 70 EPA 524.2 4/10/2006 cis-1,3-Dichloropropene BRL ug/L 0.5 EPA 524.2 4/10/2006 Dibromochloromethane BRL ug/L 0.5 EPA 524.2 4/10/2006 Dibromomethane BRL ug/L 0.5 EPA 524.2 4/10/2006 RL = Reporting Limit MCL=Maximum Contaminant Level Superior Court House, PO. Box 427, Barnstable, MA 02630 Ph: 508-375-6605 � Page: 3 �ti OF.!11Att,�,3h. �' CERTIFICATE OF ANALYSIS v MI Barnstable County Health Laboratory Report Dated: 4/12/2006 Report Prepared For: Sally Desmond Order No.: G0634986 Desmond Well Drilling P O Box 2783 Orleans, MA 02653 Dichlorodifluoromethane BRL ug/L 0.5 EPA 524.2 4/10/2006 Ethylbenzene BRL ug/L 0.5 700 EPA 524.2 4/10/2006 Hexachlorobutadiene BRL ug/L 0.5 EPA 524.2 4/10/2006 Isopropylbenzene BRL ug/L 0.5 EPA 524.2 4/10/2006 Methyl-tert-butyl ether BRL ug/L 0.5 EPA 524.2 4/10/2006 Methylene chloride BRL ug/L 0.5 5.0 EPA 524.2 4/10/2006 n-Butylbenzene BRL ug/L 0.5 EPA 524.2 4/10/2006 n-Propylbenzene BRL ug/L 0.5 EPA 524.2 4/10/2006 Naphthalene BRL ug/L 0.5 EPA 524.2 4/10/2006 p-Isopropyltoluene BRL ug/L 0.5 EPA 524.2 4/10/2006 sec-Butylbenzene BRL ug/L 0.5 EPA 524.2 4/10/2006 Styrene BRL ug/L 0.5 100 EPA 524.2 4/10/2006 tert=Butylbenzene BRL ug/L 0.5. EPA 524.2 4/10/2006 Tetrachloroethene BRL ug/L 0.5 5.0 EPA 524.2 4/10/2006 Toluene BRL ug/L 0.5 1000 EPA 524.2 4/10/2006 Total xylenes BRL ug/L 0.5 10000 EPA 524.2 4/10/2006 trans-1,2-Dichloroethene BRL ug/L 0.5 100 EPA 524.2 4/10/2006 trans-1,3-Dichloropropene BRL ug/L 0.5 EPA 524.2 4/10/2006 Trich?oroethene BRL ug/L 0.5 5.0 EPA 524.2 4/10/2006 Trichlorofluoromethane BRL ug/L 0.5 EPA 524.2 4/10/2006 Vinyl chloride BRL ug/L 0.5 2.0 EPA 524.2 4/10/2006 Sodium level is above the maximum contaminant level. Those on a low sodium diet may wish to consult a physician. Approved By• _ (L irector) RL = Reporting Limit MCL=Maximum Contaminant Level Superior Court House, PO. Box 427, Barnstable, MA 02630 Ph: 508-375-6605 Massachusetts Department of Environmental Management Office of Water Resources /�� 6 14 413 5 FfE R PRINT ONLY Well Completion Report 4 V I 1. WELL LOCATION GPS (OPTIONAL) LATITUDE _° LONGITUDE DATUM Address at Well Location:, 6-- Property Owner/Client: Subdivision Name: Mailing Address: - \vNA`\b' ' �;i ��,s City/Town: o, V. City/Town� Assessors Map . Assessors Lot A ' NOTE: Assessors Map and Lot# mandatory.if no treet,a d ess available Board of Health permit obtained: Yes + 1 Not Required ❑ Permit Number Da e lss ed )l � 2.WORK PERFORMED 3. PROPOSED USE 4.:DRILLING METHOD CA. New Well ElAbandon ® Domestic ElIrrigation ElCable `�,,� Auger Deepen ❑ Recondition ❑ Monitoring ❑ Municipal ❑ Air Hammer ,-%19 Direct Push 9ta-R_ lace ❑ Other ❑ Industrial ❑ Other ❑ Mud=Rota ':) ❑ Other 5. WELL LOG Water Unconsolidated Consolidated 6.'SITE SKETCH(use nwt1WaMB,kS With amMC05) Bearing a m m Other Rock Type �$ From (ft) To (ft) Zone �iaCn m Material Description ,,j. 7. WELL CONSTRUCTION 8. CASING Total Depth Drilled °'C� From (ft) To (ft) Casing Type and Material Size I.D. (in) Well Seal Type Date Complete + "J -S CqQ Plc.- q I'tS PLAMR 9. SCREEN From (ft) To (ft) Slot Size Screen Type and Material Screen Diameter . 52) a�—+ .017. SrA6 .ASS S 3td£L � !, 10. FILTER PACK/GROUT/ABANDONMENT MATERIAL 11. ADDITIONAL WELL INFORMATION Developed? C2 Yes ❑ No From (ft) To (ft) Material Description - -' Purpose Fracture Enhancement? ❑ Yes ER No ` Method Disinfected? ® Yes ❑ No 12. WELL TEST DATA(ALL SECTIONS MANDATORY FOR PRODUCTION WELLS) 13. STATIC WATER LEVEL(ALL WELLS) Yield,.,`-jime Pumped Drawdown to Time to Recover Recovery to Depth Below Date Method (GPM) "{ rs&min) (Ft. BGS) (hrs & min) (Ft. BGS) Date Measured Ground Surface (FT) 1€i Urru� ►ter 'L� j : C)C) -.52 b : 14. PERMANENT PUMP(IF AVAILABLE), 15.NAME/ADDRESS OF PUMP INSTALLATION COMPANY Pump DescriptionG'r'n Ue""Y6 Horsepower I 1 ,, wf—k\;fit, , n Pump Intake Depth (ft) Nominal Pump Capacity 10 (gpm) 5 Kit'. r Ti"Al n r1 Q l,x IV 6245-75, r �J 16. COMMENTS 17. WELL DRILLER'S STATEMENT This well was drilled, altered, and/or abandoned under my supervision, according to applicable rules and regulations, and this r port is complete and correct to the best of my knowledge. Driller:i` eaA I, V',(N Supervising Driller Signature: "�j��r��4r— - . 1 Registration #: �1 6 1 9 � Firm: �14I ',ts(,t�fi" �.� Date: Rig Permit#: Rjj NOTE: Well Completion Reports must be filed by the registered well driller within 30 days of well completion. BOARD OF HEALTH COPY ' WN (.1}: . A ;INS iABLF _. = MIS APR.19 Pi- 1 38 a ! 4 r � t 1 Fee-----�--- ------ No.----- BOARD OF HEALTH TOWN OF BARNSTABLE Application ArWell tonotruct on ermit Application is hereby made for a permit to Construct ('/- ), Alter ( ), or Repair ( )an individual Well at: i Location — Address \ Assessors /Map and Parcel a-v'r` Owner Address �7-65�5 Installer — Drilrff Address Type of Building Dwelling ----— -— _ --- - Other - Type of Building--- ------- No. of Persons-- =----------------------- " q Type of Well �V"`-z- `c CnSu +� 'hal� sC�14�JQc. Capacity -- Purpose of Well----------_--V-- ---- 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 plact: the well in operation until a Certificate of Compliance has been issued by the Board of Health. Signed - A --- -- CA. --- _t da 31x1/0 6 Application Approved By -- ------ date Application Disapproved for the following reasons: -- -------- --------- -- ------- ---- ---------------- - - Odate Permit No U_ a o _ 04 — Issued— l - - --date-- ---- — - - BOARD OF HEALTH TOWN OF BARNSTABLE Certificate ®f (compliance THIS IS TO CERTIFY, That the Individual Well Constructed WI), Altered ( ), or Repaired ( ) by— mil_-1_�1'� - '— -- -- —— --- ----- -- Installer athas been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Wellprot5ttion Regulation as described in the application for Well Construction Permit No.W ^0 {Dated --- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE----___ — --- - -- Inspector--------------- —------- l • W"206 r 0Q57 A Fee-- }------------ g BOARD OF HEALTH TOWN OF BARNSTABLE 2(ppticat ion,for Ver[ Con5truct ion permit f Application is hereby made for a permit to Construct (X), Alter ( ), or Repair ( )an individual Well at: o(-0 ------ — --- � 2 / -- 0a—I-- ---- Location,- Address Assessors Map and Parcel 235 \W\aw --�rt.W-T)acy4,-,r j-,PA _o2�6g v Owner Address V.o-1a-4. ' U) -Q&e nsAMA 4Z(o53 - Installer — Driller Address Type of Building ✓ IDwelling ----;-------------------------------- Other - Type of Building--------------- No. of Persons--�----------------------- Type of Well 60 vV.e�S�;c. C arS u m_p�61r.�y SC�`lOQ Capacity - Purpose of Well------------_—_ v--- = 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 � ----- ----- - --- l date Application Approved By � — ---- _— 3r°�y 0 Ydate Application Disapproved for the following reasons: ---- ----- —--- j - - - date �A - 0D S� — --_—__-- Issued— °�- Permit No.Via t 't--------date------ — ---� i ' S w.•__-n_.A_w0.11.-•. .-..b-.+Ca.--d"-3--.N:.y4-.�' .; F _ rF a., -- rti• Sn - -f'. - .. __ry'c.-+....+Y e--.-06'- .-t.. 's..(>...�y�:+R.,-+9�++!--X'<.,15-r;...'.+r- T-R'^-...au+.a'Sr+.' L"--`...� ... .n�.•F�r',.:=� ..it_.'_ r..-. Y. tipz� BOARD OF HEALTH TOWN OF BARNSTABLE Certificate Of Compliance THIS IS TO CERTIFY, That the Individual Well Constructed (r/), Altered ( ), or Repaired ( ) by- %`iv►� o —1 c� �L C= DKL L/ ,------J C. 14 — L__ Installer at — �'--__L(� 1�-LQ L-c _�z lz(---w r S�� L� I` R Srt®L Q—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.Vl1� �-U O�Dated f�-��--- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE----- ----=----- --- Inspector------------ - -- k BOARD OF HEALTH TOWN OF BARNSTABLE Ivey[ Congtructionvermit No. lJ--U�l(?-00s Fee— l— �f=SY12 Permission is hereby granted — ��---------- II to Construct Alter (" ), or Repair ( ) an Individual Well at: 'i No. --A- (-mac I I-L OCR �1- R .tt�_ -"t fit�S'T"' �12 P S t IF!•a L�--------- as shown on the application for a Well Construction Permit No.--� dU r t)0 S� ------ Dated 31 Ali -3 f DATE �4 Board of Health — i\ . i 0 �i �d � . i�� /, ,� i .. r ,� .. ,� �: � __. _ . __ ___ a ,'' `, ;.;s-. �' �-� p �'` � �I �. ._. __ � '� � '� o ,. .....�� -„� -� ,� ,...,�� v.� :._:� �`� �� _ � �. .�� ,_� �� . .. � - � -. � _._ � '��, '�crj ,,.- ...a '1. 1'J :l T OWW 200£1 MON 12: 16 FAX 5083627103 Barnstable CITY HealthLab --- Barnstable Health 03 01/001 I CERTIFICATE OF ANALYSIS Page: a I ii,C� h i Barnstable County Healthr Laboratory Report Prepared For: Report Dated: 6/27/2008 CF; i Maria Lamb Order No.. G0847096 P 0 Box 428 South Chatham, MA 02659 'La'horatury IUD#: 0847096-01 Description: Water-Drinkin-Water - ::;ample#: Sampling Location. 95 Willow St.Barnstable,MA7 Collected: 6/24/2008 Collected by: Maria Lamb Received: 6/iV2008 ITEM RESULT UNITS RL MCI. Method# Tested 1.'�i'ir to API Nitrogen 0.95 mg/L 0.10 10 EPA 300.0 6/25/2008 t� Cor.pe1 0.13 m 0.10 1.3 SM 3111 B 6/25/2008 1ro;; ND mg/L 0.10 0.3 SM3111B 6/25/2008 Sodiurn. 24 mg/L 1-0 20 SM 3111B 6/25/2008 '• P/A 0 0 SM9223 6/24/2008 Absent , i ;OriCEUc;fz:ri.r, 350 umohs/cm 2.0 EPA 120.1 6/24/2008 lad; 7.8 pH-units 0 SM 4500 H-B 6/24/2008 f l _&)di--u2,'evel%s above the maximum contaminant level. Those on a low sodium diet may wish to consult a physici n. i /A,Approved By:, (Lab Director) !!! } l i i s i 1� t } I� i i 1} i I 3 1 t 3 ND—None Detected RL = Reporting Limit MCL=Maximum Contaminant Level Superior Court Douse, PO Box 427, Barnstable, MA 02630 Ph: 508-375-... .. _------ .. ......... __.. .. { i COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF.ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM . PART A CERTIFICATION Property Address: 295 Willow Street West Barnstable, MA 02668 - �a Owner's Name: Kathy Bassett Owner's Address: Date of Inspection:: March 7, 2008 Name of Inspector:(Please Print) James M. Ford Q 3 Company Name: - James-M. Ford Mailing Address: P.O.Box 49 h' Osterville MA 02655-0049 Telephone Number: (508) 862-9400 CERTIFICATION STATEMENT I certify.that I have personally inspected the sewage disposal system at this.address.and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance,of on site sewage disposal systems. I am a DEP ' approved system inspector pursuant to Section 15:340 of Title 5(310 CMR 15.000) The system: Passes Conditionally Passes N eds.Further Evaluation by the Local Approving Authority is Inspector's Signature: Date: March 11, 2008. The system inspector shall sl a copy:of t1iis inspection report to the Approving:Authority(Board.of Health or DEP)within 30 days of completing this inspection. If the system is a:shared system or has a design flow of.10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to.the system owner and copies sent to the buyer,if applicable,and the approving authority. .. Notes and Comments ****This report'only describes conditions at the time:of inspection and under the conditions of use at that: time. This inspection does not address how the system will perform in the future under the same or different. . . conditions of use. Title 5 Inspection Form 6/15/2000 paged Page 2 of 11 r OFFICIAL INSPECTION FORM 7 NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 295 Willow Street .West Barnstable MA Owner's Name: Kathy Bassett Date of Inspection: March 7 2008 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: ✓ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: j One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in.the for the following statements. If"not determined",please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution,box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is.leveled or replaced , ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 295 Willow Street West Barnstable, MA Owner's Name: _ Kathy Bassett Date of Inspection: March 7. 2008 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning.in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: The system has aseptic 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 publicwater supply: The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water.supply well". Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate.nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of 11 . OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 295 Willow Street West Barnstable MA Owner's Name: Kathy Bassett Date of Inspection: March 7 2008 D. System Failure Criteria applicable to all systems: You must indicate either"yes"or"no"to each of the following for all inspections: Yes No ✓ Backup of sewage into facility or,system component due to overloaded or clogged SAS or cesspool ✓ Discharge or ponding of effluent.to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than %day flow ✓ 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 l00 feet of a surface water supply or tributary to a surface water supply. ✓ Any portion of,a cesspool or privy is within a Zone 1 of a public well. ✓ . Any portion of a cesspool or privy is within 50 feet of a private water supply well. ✓ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] No (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should:contact the Board of Health to determine what will be necessary to correct the failure. E. Large System: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) . Yes No the system is within 400 feet of a surface drinking water supply _ the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public.water.supply well If you have answered"yes"to any question in.Section E the system is considered a significant threat,or answered. "yes"in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 4 f Page 5 of 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 295 Willow Street West Barnstable, MA Owner's Name: Kathy Bassett Date of Inspection: March 7, 2008 Check if the following have been done: You must indicate"yes"or"no"as to each of the following: Yes No ✓ Pumping infonnation was provided by the owner,occupant,or Board of Health Were any of the system components pumped out in the previous two weeks? Has the system received normal flows in the previous two week period? ✓ Have large volumes of water been introduced to the system recently or as part of this inspection? ✓ _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) Was the facility or dwelling inspected for signs of sewage back up? ✓ _ Was the site inspected for signs of break out? ✓ Were all system components,excluding the SAS,located on site? ✓ _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions;depth of liquid,depth of sludge and depth of scum? Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance.of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes No . ✓ _ Existing information. For,example,a plan at the Board of Health. ✓ _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15:302(3)(b)]. 5 Page 6 of 11 OFFICIAL INSPECTION FORM:-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 295 Willow Street West Barnstable, MA Owner's Name: Kathy Bassett Date of Inspection: March 7, 2008 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): . N/a Number.of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example:110 gpd x#of bedrooms): 440 Number of current residents: 0 Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system.(yes or no): n/a [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings, if available(last 2 years usage(gpd)): Unavailable Sump Pump(yes or no): No . Last date of occupancy: Unknown COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc): Grease trap present(yes or no): Industrial waste holding tank present(yes or no) Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of infonnation: Unknown Was system pumped as part of the inspection(yes or no): No If yes, volume pumped: - gallons--How was quantity,pumped determined? Reason for pumping: TYPE OF SYSTEM ✓ Septic tank, distribution box,soil absorption system - Single cesspool Overflow cesspool Privy Shared system.(yes or no) (if yes,attach previous inspection records,if any) Innovative/Alternative technology. Attach a copy of-the current operation and maintenance contract.(to be obtained from system owner) Tight Tank: Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Date of installation 919183-per as-built Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of 11 OFFICIAL INSPECTION FORM-NOT.FOR.VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 295 Willow Street West Barnstable, MA Owner's Name: Kathy Bassett Date of Inspection: March 7, 2008. BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron _40 PVC _other(explain): Distance from private water supply well or suction line:. Comments(on condition of joints,venting,evidence of leakage,etc.): - SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 16 Material of construction: ✓ concrete _metal _fiberglass _polyethylene _other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 1000 gal: Sludge depth: 2" Distance from top of sludge to.bottom of outlet tee or'baffle: 30" Scum thickness: 3" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee.or baffle: 10 How were dimensions determined: Measuring stick Comments(on pumping reconunendations, inlet and.outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.):, Tees were present. The liquid level was even with the outlet invert There did not appear to be any si ns of leakage The inlet cover was 10"below grade. GREASE TRAP: None (locate on site,plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum.to bottom of outlet tee or baffle: DGte of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): L Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY.ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:, 295 Willow Street West Barnstable MA Owner's Name: Kathy Bassett Date of Inspection: March 7. 2008 TIGHT or HOLDING TANK: None (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/day Alann present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Even Continents(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.): No solids were present: PUMP CHAMBER: None (locate on site plan) Pumps in working order.(yes or no): Alarms in working order(yes or no) Comments(note condition of pump chamber,condition of pumps and appurtenances,etc:): E' 8 Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: .295 Willow Street West.Barnstable i11A Owner's Name: Kathy Bassett Date of Inspection: March 7, 2008 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site'plan,excavation not required) If SAS not located explain why: Type leaching pits,number: ✓ leaching chambers,number: _Flow-Dif ussors leaching galleries,number: leaching trenches,number, length: leaching fields,number,dimensions; overflow cesspool,number: Innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): The Diffussors were dry. There did not annear to be any signs of failure The bottom to grade was 3' CESSPOOLS: None (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 or no): Connnents (note condition of soil,signs of hydraulic failure,level of ponding, condition of vegetation,etc.): " PRIVY: None (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.): 9 f res a�n5.� lifief ►vLood-e . l�rc�t ►�a� �vj s a V-)j �r�Oo+'x,fi�►n s . e- rr4 u► o.4 I� rat �4 s 4 JA qurIC,vjA4,1 `• Page 10 of 11 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE_SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 295 Willow Street West Barnstable, MA Owner's Name: Kathy Bassett Date of Inspection: March.7. 2008 SKETCH OF SEWAGE DISPOSAL SYSTEM' Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet: Locate where public water supply enters the building. - A O Q k a r O ly 10 Page 11 of 11 OFFICIAL INSPECTION FORM-,NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 295 Willow Street West Barnstable, MA Owner's Name: Kathy Bassett Date of Inspection: March 7,2008 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 10 +/- feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) ✓ Checked with local Board of Health-explain: To1J0f?Yaphic and water contours maps Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain:. You must describe how you established the high groundwater elevation: Using Barnstable topographic and water contours.maps, the maps were showing approximately 10'+/-to groundwater at this site. This report has been prepared only for the septic system and components described herein. This septic system has been inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed,written or implied, relating to the septic system;the inspection, this report and/or any components of the septic system which have not been located and inspected. 11 LOCATION SEWAGE PERMIT NO. VILLAGE - ! f5l INSTA LLER'S NAME i ADDRESS B UILDE R R OWNER �e DATE PERMIT ISSUED f �� DAT E COMPLIANCE ISSUED 7�' J -. ='� - . �� - T ,. � �� =� �-� �, ,fir -L 1 , � 1f �'t�. v t .,`w No. 3"2 THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........)-.O t.............0F....L3tMz7m. ..)c.......................... Appliration for Diopoottl Workii Tonoanrtion Prrmit Application is hereby made for a -Permit to Construct ( ) or Repair (L man Individual Sewage Disposal System at: q _...1 �. .U .�..... .Y��............. ...... Lo n WI(Add, ss r Lot No. ..U. J . .G1 ']. T...... J' �17� ,fl�................. a ..�.. f .......... __ - a1ss--•--•-•-••---•---•-•--•-----------------•- Installer Address dType of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms..................:.........................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) a Other fixtures ------------------•----...-----...........--•- d ------------ ------------- W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ W Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. x Seepage Pit No---------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.................................•-•--........................•---•••---•• Date........................................ IITest Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Gi, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ _r ............ .................................................................................... O Description of Soil................-• < .._. - -� x -------------------------------------------------------------------------------------•--------------...............---- I U Nature of Repairs or Alterations—Answer when applicable................. ,� �4/_:.... . ...........__. --•----------------------••-----------------...1.-.,1.ru0--- - Zt-1.::k.... / ....------------------............... Agreement: 41 The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of L I L LL 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has bee issued by the oar f health. ApplicationApproved By.,.... . .............. ..........•---••---•-•-•--•-----................-•--•-•-•-•---- Date Application Disapproved f r t following reasons:...........................•--••-----...---------------------........---....-•-•-- -----.......---------•-------------•--------•--------------•--••---......-•--•---•--------........---•--.--•--•-••---•-••---•••--•----•--•--•--••-•••----•-•----•--•-. Date PermitNo.......................................................... Issued--------•---------------------•----...................: Date THE COMMONWEALTH OF MASSACHUSETTS -�i BOARD OF HEALTH Appliration for Utopooal Workii Tonotrurtion Prrutit Application is hereby made for a Permit to Construct ( ) or Repair (L- -'an Individual Sewage Disposal System at: } Lo,'pn Add �f I. Lot No. - ........ �..........._..... w e ........... .1...�� T ........................................... Installer Address d Type.of Building Size Lot............................Sq. feet U Dwelling—'No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) dOther fixtures -------------------------------•------------•-•--..................................................................................................... W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No...•-__--__..,._____-- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ ,�. Test Pit No. I................minutes.per inch Depth of Test Pit.................... Depth to ground water........................ GT4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ •-- -- ---------- •-- Description of Soil ....... z° .Y�� ' x --•--••----•----------------•----------------........------------•-•------------..........--........-----... x ------------------------------------------------------------------------------------ - - ......: U Nature of Repairs or Alterations—Answer when applicable.............. ).44! ��'....------.---. ............. f r:- ............V11 Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with i the provisions of TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in E operation until a Certificate of Compliance has bee issued by the ar f health.. Signed'--- -(�" -••* ......... ..............,....... /d/��nat Application Approved By---- ,'{ `- ................................................. --., /__;Date .-......... Application Disapproved f thllowing reasons:. .....................................................-----........------•-••---•---•---••-•-•----------•..--•----•--------•------...•---••--•---•------•----••-•---••----------------------••--•.---•--. Date PermitNo......................................................... Issued-........................................ ............... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ......./...�, ..........OF....... #R-?:1. . 'r ��✓. 1®. ...................... Trr#ifirat a of (Tout rlittnrr T IS TO CERTIFY, That the�Individyal S% ewage Disposal System constructed ( ) or Repaired (t.�.- [, -•----------------------------•-•-••---...._........ ) ) nstalker'� at_-0_2 I,�_�e�r`Z)4),_.................... ....................... .��'� ----------------•-••----•---._.......... y�"/d........ been installed in accordance with the provisions of TI ,'i 5 o tate Sanitary � descr' u d in the application for Disposal Works Construction Permit NTo.___.._. '" _ TIME ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRII AS A GUARANTEE THAT THE SYSTEM WIJE FVOCTION SATISFACTORY. DATE.... _ .-•-•---••---•..............•-•-----..:._........... Inspector is _.. --• --••-•---.....----•----------....----••----....................---•-----•- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ............... !.......OF....... e •--- No......................... FEE...................... io�ro� 1 or Tomitr ion and Permission is hereby granted......`-� ---• k?-/aza % � . .G-- �_to Const ct ) or Re air (j_'an Indivi,�ual �Ta e)Dii posal System atNo.. ... C ��L1 ' ;�/' .............................................................. Street 4�Y . as shown on the a Plylon for Disposal Works Construction Permit No.'.:__ _ _..•___.__ ated.......................................... ..........................Z_ DATE-- .................................................... Board of Health ---- FORM 1255 A. M. SULKIN, INC.. BOSTON