HomeMy WebLinkAbout0526 WILLOW STREET - Health 526 Willow Street
W. Barnstable
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Commonwealth of Massachusetts
u v Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
526 Willow St
Property Address
Palmer
Owner Owner's Name
information is required for every West Barnstable Ma 02668 11/11/14
page. Citylrown State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. General Information on the computer,
use only the tab 1. Inspector: L/A
key to move your
cursor-do not Chad Hathaway
use the return
key. Name of Inspector
H.P.S.
�-b Company Name
P.O.Box 151
Company Address
Forestdale Ma 02644
City(rown State Zip Code
774-274-2581 12866
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
i
11/11/14
Inspector's Signature Date
The system inspe/rshall submi copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 da of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins•3113 Title 5 official IVo ::: re Sewage Disposal System-Page 1 of 17
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 526 Willow St
Property Address
Palmer
Owner Owner's Name
information is required for every West Barnstable Ma 02668 11/11/14
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
tank o.k tees in place liquid level at bottom of outlet pipe no visable leaks or cracks. Dbox clear of
carry overs no visable cracks. leach pit 4' pit dry at time of inpsection. staining 18" below invert
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no"or"not determined"(Y, N, ND)for the following statements. If"not
determined," please explain.
The septi--tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 2 of 17
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
526 Willow St
Property Address
Palmer
Owner Owner's Name
information is required for every West Barnstable Ma 02668 11/11/14
page. City town State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes(cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
R Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 526 Willow St
Property Address
Palmer
Owner Owner's Name
information is required for every West Barnstable Ma 02668 11/11/14
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health(and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes"or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than Y2 day flow
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 or 17
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 526 Willow St
Property Address
Palmer
Owner Owner's Name
information is required for every West Barnstable Ma 02668 11/11/14
page. Citylrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,
or answered"yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
11.9 Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
526 Willow St
Property Address
Palmer
Owner Owner's Name
information is required for every West Barnstable Ma 02668 11/11/14
page. Cityfrown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
❑ ® Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5))
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 3
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
526 Willow St
Property Address
Palmer
Owner Owner's Name
information is required for every West Barnstable Ma 02668 11/11/14
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes ® No
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)):
Detail:
well
Sump pump? ❑ Yes ® No
Last date of occupancy: Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
526 Willow St
Property Address
Palmer
Owner Owner's Name
information is required for every West Barnstable Ma 02668 11/11/14
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: owner
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology.Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
526 Willow St
Property Address
Palmer
Owner Owner's Name
information is required for every West Barnstable Ma 02668 11/11/14
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
1978
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 7'feet
Material of construction:
® cast iron ®40 PVC ❑other(explain):
Distance from private water supply well or suction line: 25+
feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
Septic Tank locate on site plan):
( P )
Depth below grade: 8'feet
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain)
If tank is metal, list age: years
1s age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
1000 gal
Sludge depth:
2"
l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 526 Willow St
Property Address
Palmer
Owner Owner's Name
information is West Barnstable Ma 02668 11/11/14
required for every
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
24"
0"
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
How were dimensions determined?
visable inspection 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.):
pump every 2 years as maint.
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
t5im>•3113 Title 5 Official Inspection Form:Subsurface specti Sewage Disposal System•Page 10 of 17
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 526 Willow St
Property Address
Palmer
Owner Owner's Name
information is required for every West Barnstable Ma 02668 11/11/14
page. City(rown State Zip Code Date of Inspection
D. System Information (cont.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping:
Date
Comments(condition of alarm and float switches, etc.):
Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•3/12 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
526 Willow St
Property Address
Palmer
Owner
Owner's Name
information is required for every West Barnstable Ma 02668 11/11/14
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cons.)
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.):
no carry overs no visable leaks
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
*If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
pit inspected and was dry at time of inspection. staining 18" below invert
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
526 Willow St
Property Address
Palmer
Owner Owner's Name
information is required for every West Barnstable Ma 02668 11/11/14
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: 1
❑ leaching chambers number:
❑ 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.):
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
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 526 Willow St
Property Address
Palmer
Owner Owner's Name
information is required for every West Barnstable Ma 02668 11/11/14
page. CityrFown State Zip Code Date of Inspection
D. System Information (cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 526 Willow St
Property Address
Palmer
Owner Owner's Name
information is requ fired for every West Barnstable Ma 02668 11/11/14
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
�0
9 0
� I
t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 15 of 17
Commonwealth of Massachusetts
19
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
5. 526 Willow St
Property Address
Palmer
Owner Owner's Name
information is required for every West Barnstable Ma 02668 11/11/14
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water: feet
Please indicate all methods used to determine the high ground water elevation:
i ❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health-explain:
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
41.6999N-70.3903W elevation 92
You must describe how you established the high ground water elevation:
usgs topo map
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
IM
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 526 Willow St
Property Address
Palmer
Owner Owner's Narre
information is required for every West Barnstable Ma 02668 11/11/14
page. Cityrrown State Zip Code Date of Inspection
E. Report Completeness Checklist
❑ Inspection Summary: A, B, C, D, or E checked
❑ Inspection Summary D(System Failure Criteria Applicable to All Systems)completed
❑ System Information—Estimated depth to high groundwater
❑ Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
Page: 1 of 1
CERTIFICATE OF ANALYSIS
Barnstable County Health Laboratory (M-MA009)
ys,•„ _�.�' Report Prepared For: Report Dated: 11/21/2014
Chad Hathaway
Hathaway Property Services Order NO.: G1484382
P O Box 151
Forestdale, MA 02644
Laboratory ID#: 1484382-01 Description: Water-Drinking Water
Sample#: Sample Location: 526 Willow St.W. Barnstable, MA Collected: 11/12/2014
Collected by: C. H. Received: 11/12/2014 j
Routine
ITEM RESULT UNITS RL MCL METHOD# TESTED
Nitrate as Nitrogen 1.0 mg/L 0.10 10 EPA 300.0 11/12/2014
Copper ND mg/L 0.10 1.3 SM 3111E 11/20/2014
Iron ND mg/L 0.10 0.3 SM3111B 11/20/2014
pH 6.2 PH AT 25C NA 6.5-8.5 SM 4500-H-B 11/12/2014
Sodium 190
mg/L 2.5 20 SM 3111 B 11/20/2014
Total Coliform Absent P/A 0 0 SM 9223 11/12/2014
Conductance 960 umohs/cm 2.0 EPA 120.1 11/12/2014
Sodium level is above the maxium contaminant level. Those on a low sodium diet may wish to consult a physician.
Attached please find the laboratory certified parameter list.
Approved By:
(Lab Director).
A 1:2
ND=None Detected RL = Reporting Limit MCL=Maximum Contaminant Level
Superior Court House, PO. Box 427, Barnstable, MA 02630 Ph: 508-375-6605
CERTIFICATE OF ANALYSIS
MI
Barnstable County Health Laboratory (M-MA009)
..SaCflliSt
I Recipient: Chad Hathaway Matrix: Water-Drinking Water
Hathaway Property Services Sampled: 11/12/2014 10:00 {
P O Box 151 Received: 11/12/2014 10:20
Forestdale, MA 02644 Collection Address: 526 Willow St.W.Barnstable, MA
Sample Location:
,'Order#: G1484382 Description: rkt
Lab ID: 1484382 O1 Date Analyzed: 11/13/2014 @ 13:47
i Sample#: Analyst: yn
I Method: EPA 524.2 Dilution Factor: 1
,
Comment: Sodium level is above the maxium contaminant level.Those on a low sodium diet may wish to consult a physician. I
EPA 524.2 - Volatile Organics by GC/MS
- Result I MCL MDL 1 - - -- -- Result MCL�- MDL
-Parameter ! ug/L lug/L ! ug/L i Parameter ug/L I ug/L ug/L
I S0 ! - 0.50
`Dichlorodifluoromethane ND i 0.50 ;(Chloroform _
Chloromethane ND i i 0.50 1icis-1,2-Dichloroethene ND ; 70 0.50
I
;Vinyl chloride ND 2_0 0.50 ,cis-1,3_Dichloropropene ND O.so
_ _____________________ --- 1-
Bromomethane j ND ) 0.50 - IDibromochloromethane _ND 1 0.50
'1,1,1,2 Tetrachloroethane f ND - 0.50 ;Dibromomethane i ND ( o.so
- -' ---- -
- ; � f ND 700 - 0.50
;1,1,1-Trichloroethane ND 200 0.50 iE~thylbenzene -
1,1,2,2-Tetrachloroethane j ND I o.so ijHexachlorobutadiene ND ! 0.50 j
- -- -1 i
j1,1,2 Trichloroe_thane ( ND 5.0 ; 0.50 111sopropylbenzene ND I 0.50
-- -- -- - -
--- ! 0.50 ! Meth lene chloride ND 5.0 0.50
0.50 !
i1,1-Dichloroethane j ND -_ y -
- - - j 7.0 i o.5o I jMethyl-tert-butyl ether ND 0.50
11,1-Dichloroethene ND 1 I -
'1,1-Dichloropropene ;• ND I 0.50 IiNaphthalene ND 0.50 ;
11 2 3-Trichlorobenzene ND I 0.50 iIn-Butylbenzene ND i 0.50
--- ---
11,2,3-Trichloropropane ! _ ND 0.50 n-Propylbenzene ND 1 0.50
i1,2,4-Trichlorobenzene ND 70 ; 0.50 ;p-Isopropyltoluene ! ND� 0.5o i
1,2,4-Tri methyl benzene i ND i i 0.50 1 sec-Butyl benzene { ND 0.50
j1,2-Dibromo-3-chloropropane ND 15 rene ! 100_1 0.50
0.50 4' ------ - --- -...N�=-- -- --
1,2-Dibrornoethane(EDB) - -ND j 0.50 j�tert-Butylbenzene ND O.So
i4 2-Dichlorobenzene ND ! 600 0.50 1 TTetrachloroethene ND 5.0 0.50 }
1,2-Dichloroethane ND 5.0 0.50 ;Toluene ND-_ T j 1000 0.50 -
1,2-Dichloropropane j ND ' 0.50 i Total xylenes ND 110000 0.50 R
j1,3,5-Tri methyl benzene ND 0.50 trans-1,2-Dichloroethene j ND j 100 ( 0.50
1,3-Dicf dorobenzene ND ! ! 0.50 _;trans-1,3-Dichloro_propene i ND j -0.50
.' 3-- ----------"-'-- I ;
11,3-Dichloropropane ND 0.50 ITrichloroethene ! ND 5.0 0.50
'1,4-Dichlorobenzene ND ' 5.0 0.50 Trichlorofluoromethane 1 ND _ i i 0.50
2,2-Dichloropropane- - _ ND 0.50 Surrogates %Recovered j QC Limits(%)!
2 Chlorotoluene j ND - oso !p_gromofluorobenzene { 92% 70� 130 j
--- ---- t
14-Chlorotoluene f ND I i 0.50 11,2-Dichlorobenzene-d4 -98% -70 130 a
iBenzene ND 5.0 0.50
iBromobenzene ND 0.50
Btomochloromethane ND ; 0.50
iBromodichloromethane - i - ND 0.50
IBromoform ND 0.50
'Carbon tetrachloride- ND 5.0 0.50
'Chlorobenzene - ---- ------- ND - 100 - 0.50
IChloroethane ND 0.50
Approved 8 ' -- - �--'� --
Attached;please find the laboratory certified parameter list. (Lab Director)
ND=None Detected RL = Reporting Limit MCL=Maximum Cont minant Lev l
Superior Court House, PO. Box 427, Barnstable, MA 02630 Ph: 508-375-6605 Page 1 of 1
Massachusetts Department of Environmental Management SUN 1 6 20 CIQ e 1
' Office of Water Resources J
TYPE OR PRINT ONLY Well Completion RepOrt-
Lr 13r��itiJi.ti�LE
1.WELL LOCATION GPS (OPTIONAL) LATITUDE L
Address at Well.Location. Property Owner:
Subdivlsion Name. Mailing Address. �lF -
City/Town City/Town:. Qo1v _:
Assessors Map Assessors Lot#: NOTE: Assessors Map and.Lot#mand t e atory if no et add ss a ay able*
Board of Health permit obtained: Yes LI Not Required. ❑ , Permit Number� ��"��Dafe,Issued °. i , �
2.WORK PERFORMED 3, PROPOSED USE 4.DRILLING METHOD
❑ New Well ❑ Abandon Lf Domestic ❑ Irrigation ❑ Cable , >`t `El/Auger
❑ Deepen 0 Recondition ❑ Monitoring ❑ Municipal El Ai Hammer`❑ Direct Push
-'Re lace ❑ Other ❑ Industrial ❑ Other JJ MudAota ; El Other
5. WELL LOG. cc Unconsolidated Consolidated 6. SITE SKETCH (use permanent landmarks with distances)
W Permeability
From(ft) To (ft)
h Lo Higw UM) m Other Rock Type
y
a '-
� � 4
7. WELL'CONSTRUCTION 8: CASING r
Totaf.Depth Drilled; 9Js-t From`(ft) To(f#) Casing Type and.Material Size 0 D:'(in) 1Nell SeafType .
Date Drilling Compl te' h�
lA�/ 5 oa
9. SCREEN
` From (ft) To (ft) Slot Size Screen Type and Material Screen Diameter
9S is 77777 77
10. FILTER PACK/GROUT/ABANDONMENT MATERIAL 11. ADDITIONAL WELL INFORMATION
' �• Developed? El Yes ❑. No
From (ft) To (ft) Material Description`,, Purpose Fracture
A Enhancement? d Yes ❑ No
a Method
Disinfected? [I Yes ❑. No
12. WELL TEST DATA(PRODUCTION WELLS) 13. STATIC WATER LEVEL(ALL WELLS)
Yield NTjme Pumped Drawdown to Time Recovery to Depth Below
Date' Method (GPM), `(hrs&min) (Ft.BGS) (hrs &min) (Ft. BGS_) Date Measured Ground Surface (FT)
14. PERMANENT PUMP(IF AVAILABLE) , 15:NAfit1E/110QRESS Of P(JMP tNSYALLAFtQN COMPAfdY= -'
Pump Descriptionr1r.P�. Sl/6J �°Si wer Horsepo P'
p: ;
Pump Intake Depth - t (ft)_; Nominal Pump Capacity`, (gpm). -
16.COMMENTS � .
' 17. WELL DRILLER'S STATEMENT This well was drilled and/or abandoned under my supervision, according to applicable rules
and regulations, and this rep is_complete and correct to the best of my knowledge.
Driller: � Supervising Driller Signature: Registration #:I 1 /1 3�l V¢
l
Firm: �J7� i ' Date: �� Rig,Permit#: 3
NOTE: Well Completion Reports must be filed by the registered well driller within 30 days of well completion.
i dGrffi� .1 '#'.if4'4t ,.t?,• t , c - .. -.. -
,�;..��x����:� ��..,xt< ;<g,�;�+;, -�x �R :.� �; BO:ARDOF°HEAL?HCOPI��.' ,`:',`�� :,� �t-•fia �;r�` ' ' a,_�"c.. �'v' ,i
�•- k z$ .{trtit.,r'!'x4zi der..$",+4 -3♦ a-. _ .. .. c.x't .. � -._
.t-..\ .♦ t'i k ..i' P `k�.-k:.{... P i t f 2 i t t r i .4�a 4 s Y..E s x s
7
No. Fee----
BOARD OF HEALTH
TOWN OF BARNSTABLE
laionVcApi Lion Permit
Application is hereby made for a ermit to Construct K-2A1te)r ( or Repair ( )an individual Well at:
i3o-o
Locati — Address —Assessors Map and Parcel
'A
Owner f Address
Installer Driller ZX/4— Address
Typ
e of B g
welling
Other - Type of Building No. of Persons------------.
Type of Well Capacity
Purpose of Well----
Agreement:
The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The
Town of Barnstable Board of Health Private Well Protection Regulation — The undersigned further agrees not to
place the well in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed
to
,r
Application Approved By— tl!
2-
date
Application i Milawilig ?erjM%ft-_—n,4
Pe r.-I. QrJ,,,t/ A�c
f date
Permit No. Issued z date
BOARD OF HEALTH
TOWN OF BARNSTABLE
Certificate & (Compliance
THIS IS TD CERTIFY That the Irldividual Well Constructed Altered or Repaired
by— ------- —-------
taller
at —-------
has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection
Regulation as described in the application for Well Construction Permit No. Dated
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL
SYSTEM WILL FUNCTION SATISFACTORY.
DATE Inspector
jo
� � �,•yl f_.i , (.,fib+�,.
fNo-—'-'1 --OO:Z---- I i Fee--------------------
BOARD OF HEALTH
TOWN OF BARNSTABLE
Cication or eil Co0truct ion Vermit
Application 's hereby ade for a -ermit to Construct ( )LAIte)r ( ), or Repair ( )an individual Well at:
.Jv�r GUI/%Cy �.S' U ��
—— _-- Locati /�— �dydJress — — —-- _ /4 A�ss�es)sors M and Parcel --
Owner Add
�c//
-- ----------------------------------------- ----- ---------------
Installer — Driller Address
Type o "I
ing
twelling _____----------------------------
Other - Type of Building---- ------- No. of Persons-----------------------------
Type ^'
YP of Well -.—_—__.__---_—__-- Capacity—_--------__—__--_--___--
Purpose of Well --- —
Agreement:
The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The
Town of Barnstable Board of Health Private Well Protection Regulation - The undersigned further agrees not to
place the well in operation until a e ificpate .00ff Compliance has been issued by the Board of HeU,�
Signed G�i�G� �? %��Q-�1'?� -- - - C—
��""' to
Application Approved By ` I' u� __ ------— __-�1 G Z
Application crr�fo owmg reaso16 �� l/' NV_- '° �'� _
pk`c/ w �rh iNlr,�ti F/l�
— date
asZ
Permit No. - I _— Issued -- -z=-----------__
` date
i
BOARD OF HEALTH
TOWN OF BARNSTABLE
Certificate Of Compliance
THIS IS C RTI That the I divid al e 1 C nstructeAltered ( ), or Repaired ( )
/��1 ��, ,cl /�,�,7u 12' li/�i�/ GGG��,o.
by-- — _ — - - -------— -- -------
Installer
.s"�� Gam- .�,� —
has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Pr tection
Regulation as described in the application for Well Construction Permit No. ���`� �� -Dated
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL
SYSTEM WILL FUNCTION SATISFACTORY.
DATE------- -- -- Inspector—_----------___—_____------____--
BOARD OF HEALTH
TOWN OF BARNSTABLE
Ivell construct ion permit
No. -w a 0 d 2-�� Fee- ----
Permission is hereby granted __ ------------
to Construct Alter ), or lair ( ) a In/d�' 'idual Well at:
No Street
as showon the application for a Well Construction Permit /
No.- `a UU / f D teed -! �-
ll
A (� Board of Health
DATE �� 41
�l i p rr
ENVIROTECHLABORA TORTES,INC.
MA CERT.NO.:M-MA 063
449 Me. 130
Sandwich, MA 02963
908(888-6460) 1-800 339-6460
FAX(908)888-6446
CLIENT: George Palmer LOCATION: 526 Willow St.
ADDRESS: 526 Willow St. W. Barnstable, MA
W. Barnstable, MA 02668
COLLECTED BY. Meehan Wells SAMPLE DATE: 6/25/2002
SAMPLE TIME: NA
WATER SAMPLE TYPE. New Well DATE RECEIVED: 6/25/2002
LAB I.D. #: 0206570
WELL SPECS.: 95750,
RESULTS OF ANALYSIS:
Parameters Units Recommended Results Method Date Analyzed
Limits
Coliform bacteria / 100ml 0 0 9222 B 6/25/2002
pH pH units 6.5-8.5 6.29 4500 H+ 6/25/2002
Conductance umhos/cm 500 730 120.1 6/25/2002
Nitrate-N mg/L 10.0 0.46 300.0 6/25/2002
Nitrite-N mg/L 1.00 < 0.004 300.0 6/25/2002
Sodium mg/L 20.0 141 200.7 6/25/2002
Iron mg/L 0.3 < 0.1 200.7 6/25/2002
Manganese mg/L 0.05 < 0.008 200.7 6/25/2002
COMMENTS: pH is below recommended limit and may have corrosive characteristics.
Sodium indicates possible salt water intrusion or road salt run off.
<=less than ✓� Date Sri L`l L✓
>=greater than R ald J. Saa
TNTC=too numerous to count Laboratory Director
L0C T7 SEWAGE PERM q
VILLAGE
INSTAnR'S N E IADDRESS
!R OR OW ER
DATE PERMIT ISSUED l `
DAT E COMPLIANCE ISSUED � � �'
i
�j�
..
THE COMMONWEALTH OF MASSACHUSETTS
1 c�� BOAR® OF HEALTH
P ........OF............... ... �..............................................
Allp ira#ion for Uiiputia1 Works Tumtrnrtiun Fumit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
.................................... .......... A.6 Z zt F/�?/c.....:...........
Lo ion ess or Lot No.
Owner d ess
Installer Address
d Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms_________________________ Expansion Attic ( ) Garbage Grinder ( )
.-, --- -----
Other—Type e of Building USC_.._..... No. of persons........................... Showers — Cafeteria
t� YP g ------------ P ( ) ( )
a Other fixtures ......................................................
WDesign Flow..............................................gallons per person per day. Total daily flow..._._...._.__y..........................gallons.
* Septic Tank—Liquid capacity./:(3?allons Length................ Width---.._--___--__- Diameter................ Depth_..............
� Disposal Trench—No_____________________ Width....1�i........ Total Length...�_,2,.... Total leaching area___.s��.__..__sq. ft.
Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box (//f 1 Dosing tank ( )
Percolation Test Results Performed by------------------•-----------.......-•--------•-•---...----------------- Date........................................
aTest Pit No. 1-._....O____minutes per inch Depth of Test Pit.._����.___.. Depth to ground water.... '' '. ..
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
- � ---------- -------- -------•--•-----•------.--.--------------------------------•-
� "Descnption of Soil .1
U ------•------------------•--------------------•........--------•-•--------------••-----.......---------......------•-•-------------•-------•---•-•-----•--•-...------........-----•-------------•---•--
W ----------------------------------------------------------------------------------------------------------------------------------------------------------------------••......------_...--
U Natur of Re airs or Alterations—Answer when applicable.----_-......... ................... . . ..................
-------- --- -
Agreeme t: f/
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
h the provisions of iITL L 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the b and of ealth.
igned __....._.. .. ..
/ Date
Application Approved By---------- :i�-- .. n...... 7-1`� 7
Date
Application Disapproved for the following reasons-----------------------------------------------------------------------------•-....._.....-----------------------
........--------------...---------...------------•-••---•-•--....-•----------------------------------------•-••-----------------------•- ••--•---•-----•---•------------- ...............................
Date
Permit No..................... z —.
--•-•----------------------•-------- Issued.--•---7-�.�-�'�:-----------•----•--------------
Date
.........................
No............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF, HEALTH
OF...... ..... . ...
ew.................................................
t--- ---------------
Appliratijan for Bi-silos Works Toutitrurtion Prrutit
Application is hereby made for a Permit to Construct. or Repair an Individual Sewage Disposal
S tem 4
A ?f.r....... ......................... .......... ................
o iont es or Lot No.
y 110
-1
TU
LA
.......................Owner1.1..................
....................
...... ....
ItIcel.. .............. .............>.
----------
dres
...........
Installer Address
Type of Building Size Lot............................Sq. feet
U —No. of Bedrooms..............::.:..........................Expansion.,ji Garbage Grinder (
Dwelling ttic
aOther—Type of Building ......... No. of persons.......................... Showers Cafeteria (
Otherfixtures ............................................................................................................. .................................
Design Flow............................................gallons per person,per day. Total daily flow__._._.....-..._A -..P....................gallons.
9 Septic Tank—Liquid capacity.A-V.441lons Length.....'7 -------- Width................ Diameter..._... DeQ1
WWidth.... 4-------------
Disposal Trench—No. .................... fe........ Total ._1.Z.... Total leaching area.....r...........sq. ft.
Seepage Pit No_____________ ______ Diameter.... .... ...7....... Depth-below inlet.._...._ ....... Total leaching area...................sq. ft.
Z Other Distribution box (jolr Dosing tank
Percolation Test Resul Performed by' Date......................
"Depth...to ground water.........*........*------
-------------------------- *----------------------
Test Pit No. I...Uso-----minutes per inch Depth of Test Pit... ...........
Test Pit No. 2................minutes per inch Depth of Test,Tit...... ........... Depth to ground,water........................
.................... .........
z--------------------------------------------------------------
-- - - ---------Z
.s ...
0 Description of Soil...... ..Q. 4.. .......... .� y.......... ...................................................................
U�4 ...................................................................................:................................
------------------------------------- ---------------- ..................
........................................................................................................... ......................................................................................
U Naturpof Repairs or Alterations—Answer when applicable------------
.......... .
--- -..-------- . .... ...
. ... Y ..SJ .0. �.......wriA ..... .. .......... ..
Agree'mek:
The undersigned agrees to install the aforedescrilbed Individual Sewage Disposal System in accordance with
the provisions of TiTIE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
igned ----- V ,
................................. ................................
..;7,/ 7r
Application Approved By.......... --
------------------- ----*--------—----- -- ------
Date
----------
Application Disapproved for the following reasons:..................................................................................... ..........................
.........................................................................................................................................................................................................
Date
PermitNo........................................................... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF EE H
..........7.i 100714 -4.�.......�OF................ ................................................................
(Infifirab of Tompliatta
THY�S-6T,9 CERTIO, That the Individual Sewage,Disposal System constructed or Repaired
................................................
...........
by............(1 -...................... ...........
al
at ..... --------------
...... ................. ................ ........... . ...........................................................................
has been installed in accordance with the provisioiYs. of T State Sanitary Code. as descrilied in the
application for Disposal Works Construction Permit No..................AOT .......... dated......77'/r*------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................................................................. Inspector........------------------------...................................................................................
.
THE COMMONWEALTH OF MASSACHUSETTS
BOARDYHEALTH,
.... .. ..............................................
....... OF...
FE E... ...............
...............................................
Permission .
is-Ilereby granted........
to ConstructA I or RAair/9 an Individual Sewage Disposal System
at ........................................................................................... ....... ..................................
Street ll
as shown on the application for Disposal Works Construction Per 0....... Tated..
.. .......................
Board of Health
DATE....5 I ..........................
Z
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