Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Home
My WebLink
About
4259 MAIN ST./RTE 6A(BARN.) - Health
4259 Klein tree'URte 6A (Bairn) Barnstable F/R, i a e MW Massachusetts Department of Environmental Protection Bureau of Resource Protection t. Well Completion Reports it Well Driller Please specify work performed: Address at well location: -j New Well Street Number: Street Name: 4259' ROUTE 6A a Please specify well type: Building Lot#: Assessor's Map#: Irrigation j Assessor's Lot#: ZIP Code: Number Of Wells: 02637 Cityrrown: Well Location BARNSTABLE In public right-of-way: GPS Yes (-No North: West: 41.70150 70.26755 Subdivision/Property/Description: Mailing Address: click here if same as well location address' Property Owner: Street Number: Street Name: DAVID REID 479 PO BOX City/Town: State: Engineering Firm: BARNSTABLE MASSACHUSETTS ZIP Code: 02637 Board of health permit obtained: (-Yes C-Not Requir� Permit Number: Date Issued: �'�W2016_.033� fj12/22/2016 j l Massachusetts Department of Environmental Protection Bureau of Resource Protection—Well Driller Program x Well Completion Reports(General) Well Driller - General Well Form DRILLING METHOD Overburden Bedrock u ger W Choose Bedrock-- WELL LOG OVERBURDEN LITHOLOGY _ �in drill Extra fast or slow Loss or additi� From(ft) To(ft) Code Color Comment Dro p on stem drill rate of fluid 20 Silty Sand Brown YES NO Fast Slow Loss Addition ((20 ((35 Silty Sand Brown ` � f: YES N 'Fast °Slow j I ......... i.,._.__..___ _.� — O _�.... Loss Addition 35 40Medium Sand Brown =YESNO r Fast 'Slow =..sAdIdition 40 60 Fine To Coarse S + -Brown ± t Fast Slow '' FYES . . NO ................................................................................................._.....................__-_......................._..................._..........._......_........................__...._.._..............._ .....................................................................- ::::::::::::::::::::::::......:::::::::::::::::.. -� , ,-' t f—__-� 60 75 j Fine To Coarse S ! Bro-wn r'Fast r'Slow i _j __- Loss Addition YES NO..._.. t .._.._._._..........._.... .._.,_..,_._..: _ : :...:.. WELL LOG BEDROCK LITHOLOGY (. Y r.............._....._................. _ ............................................................__........................_....................................................t..................,..............................:.............................._........_........................................................................................................,.........................r...................... ..... t 1 Loss or 1 Extra I Drop in Extra fast or _. I Visible Rust From(ft) To(ft) Code Comment `!addition of 'Large drill stem slow drill rate i fluid Staining Chips _ i ( Choose Code I Yes Yes: L_.-....__..� YES NO Fast Slow Loss Addition .....:.............. __ __ mmm- ADDITIONAL WELL INFORMATION Developed Yes r No Disinfected Yes No Total Well Depth 75 Depth to Bedrock None Yes i Surface Seal Type racture Enhancement (" is No �._.. � .._..._...VVV.__.......yVJ.....� ......................................................................... CASING Is Casing above ground? ............ype ��............:........................................................................................................................................................................................................................................................... ... From To T Thickness Diameter Driveshoe ....... 71 .. Polyvinyl Chloride l �. ,.•_.•� ( ...:....._.� w. Schedule 40 4 Yes SCREEN No Screen .......:......... From To Type Slot Size Diameter ___ Stainless Steel Well Point "' K012rv„rvf WATER-BEARING ZONES �DRY WELL From To Yield(gpm) 35.........................1 75......................... �............................ I PERMANENT PUMP(IF AVAILABLE) Massachusetts Department of Environmental Protection • � Bureau of Resource Protection—Well Driller Program Well Completion Reports(General) ;3 Wire Variable Speed Pump Description Horsepower Submersible �1/2� Pump Intake Depth(ft) 71 Nominal Pump Capacity(gpm) 20 ANNULAR SEAL/FILTER PACK Water Batches .Method Of From ToMaterial1 !Weight Material 2 Weight (gal) .... (count) Placement ..................................................... .... __.................. --. -------- ....... ..__..._..... ---------_...... .............................. } Choose Material Choose Material , .... Choose One WELL TEST DATA _... 3 . I [Time Pumped Pumping Level(ft Time To Recover Recovery(ft Date Method Yield(gpm)i (HH:MM) BGS) (HH:MM) BGS) 02/07/2017 Constant Rate Pump ;12 1:30 37 0:01 35 —� WATER LEVEL .............................................-----........................................._................................_............._._..............................._............... Date Static Depth BGS(ft) Flowing Rate(gpm) (Measured 1---........_.............._..........__.................._.._....._... - _.......__.._..__.............._...._.... �02/07/2017 . .......... '35 COMMENTS WELL DRILLERS STATEMENT This well was drilled or altered under my direct supervision,according to the applicable rules and regulations,and this report is complete and accurate to the best of my knowledge. Supervising Driller DESMOND WILLIAM Monitoring[M] III, DrillerUROUHART Registration# 764 Signature THOMAS,E DESMOND WELL Date Job Complete Firm DRILLING INC. Rig Permit# 023 NOTE:Well Completion Reports must be filed by'the registered well driller within 30 days of well completion' Page: 1 of 1 OD/ CERTIFICATE OF ANALYSIS It Barnstable County Health Laboratory (M-MA009) cHus! Report Prepared For: Report Dated: 2/13/2017 Sally Desmond Desmond Well Drilling Order No.: G1798147 P O Box 2783 Orleans, MA 02553 _........._...................-...-...........-----..._..................-..---- Laboratory ID#: 1798147-01 Description: Water- Irrigation Well Sample#: �Sample_Location_ 44259 Main StJ Rt.6A, Barnsfable- Collected: 02/06/2017 Collected by: DWID _ Received: 02/07/2017 Routine_M ITEM RESULT UNITS RL MCL METHOD# ANALYST TESTED NOTE Nitrate as Nitrogen 6.8 mg/L 0.10 10 EPA 300.0 LAP 2/7/2017 Iron 0.18 mg/L 0.10 0.3 SM 3111E LAP 2/13/2017 Manganese ND mg/L 0.026 0.050 SM 3111B LAP 2/13/2017 pH 6.3 PH AT 25C NA 6.5-8.5 SM 4500-1-1-13 " DCB 2/7/2017 Sodium 15- mg/L 2.5 20 SM 3111B LAP 2/13/2017 Total Coliform Absent P/A 0 0 SM 9223 RG 2/7/2017 Conductance, 190 umohs/cm 2.0 SM 2510E DCB 2/7/2017 Irrigation Well: 75Y35' J Approved B . Attached please find the laboratory certified parameter list. A pp Y' (Lab Directorp ND=None Detected RL = Reporting Limit MCL=Maximum Contaminant Level 3195 Main Street, P0, Sox 427, Barnstable, MA 02630 Ph: 508.375-6605 i 4• � No. Fee BOARD OF HEALTH TOWN OF BARNSTABLE ZIppYicatiou jfor Yell Cow5tructiou Permit Application is hereby made for a permit to Construct Alter( ), or pair ) an in 'v' 1 well at: Location-A dress Assessors Map and parcel Owner Address �QVVQ." Qfi%y�A `'AL U rn. 2143. Orua.,s Installer-Driller �� Address Type of Building Dwelling Other-Type of Building No. of Persons Type of Well W' S Q-,AL{O 'P Capacity '-0+ Purpose of Well Agreement: The undersigned agrees to install the afore described 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 1 Date Application Approved B PP PP Y D e Application Disapproved for the following reasons: Date Permit No. OL53Issued at -------------------------------------------------------------------------------------------------------- BOARD OF HEALTH TOWN OF BARNSTABLE Certificate of Compliance THIS IS TO CERTIFY,that the individual well Constructed(4 Altered( ), or Repaired( ) by Installer at has been installed in accordance with the provisions of the Town 6f BarnsUblB r Health Private Well Protection Regulation as described in the application for Well Construction Permit Noated THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORILY. Date Inspector )4 No. / Fee BOARD OF HEALTH TOWN OF BARNSTABLE Application -for Vern Con5truction hermit Application is hereby made for a permit to Construct(J), Alter( ), or pair ) an indivi&4el well at: C\ Location-Address Assessors Map and Parcel Owner Address t�e�vr �WQ\\ ���,1\;�A \�L � ��` �� 2-,�s. ol�� ,l " (2 � Installer-Driller Address i Type of Building Dwelling J Other-Type of Building No. of Persons + Type of Well L� S Capacity 2 O t ,\ V Purpose of Well uS,, Agreement: The undersigned agrees to install the afore described individual well in accordance with the provisions of the ,I Town of Barnstable Board of Health Private Well Protection Regulation J 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 1.Z Date Application Approved B PP PP Y / Dae Application Disapproved for the following reasons: Date . Permit No. (/i Issued' Date BOARD OF HEALTH TOWN, OF BARNSTABLE Certificate of Compliance j THIS IS TO CERTIFY,that the individual well Constructed(A Altered( ), or Repaired( b 4 y � S1�v,o� �� � li Installer has been installed in accordance with the provisions of the Town f Barnstabl B ar f Health Private Well Protection Regulation as described in the application for Well Construction Permit No� ' Y'ated THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORILY. Date Inspector BOARD OF HEALTH TOWN OF BARNSTABLE Yell Congtruction Permit No. I &111'2- Fee Permission is hereby granted to nL Installer J 1 to Construct( ), Alter( ), or Repair( an individual well at: No. �� ZS`1 �+� S-l- 'Q Cwnr �i Street ,,331)ated as shown on the applicationVaeil Construction Permit No. Date / Approved By I� FLOOD ZC1 c; •. 1� 100.i5 RE:f-FRFNC UPi3/217 �- 100.00 PK E T 00.28 9P o S-yq�r UP /218 t 1 x 1 0.39 106.19 / �0 :ON M OE�" Ci 6' 99.90 �►/� N -76.06 00, 76" 0.61 / lle0. 99.8E ? 00 CB/DH/FND 101.15 / �� 99.72 1% 0.06 101.54 10# 99.61 v, x Z 101.0 C 100.40 T x 99.40 Q, D ck L 100.74 Benchmark set L ra Right corner y� bottom step ##4259 E1.=101.40 Q l a 100.84 (Assured) � (Assumed) 6�15TIP i 99.41 C ��SL u G S,fJI 90L 101.74 .76 3 SE TIC/ D 99.80 x p ti 101.89 X x 100.2 10 ;L 101. to .02 Deck A N 1 0.18 x fo � 4 • q 102,04 •• 11 102.73 101.8 BRCI�PED36 02.77 102.52 ` x `ti 101.56�, • OL 10 81 I - LLY 1.01.1.6 -ZONECl7V 100,44 x 1 To EC,• $D. x a, �� T-o P u a= C3 c.�a y�L LA pp 7p Q, ^'L -=_ _ s •" I 9A 8FT-DIAMR ` . . 101.2 h �:.. - 6. x l ,f F • 1 � 100.88 ; lIlk 5. S 14 Q, 20 Pa. g 100 .81 -OoF . 4IN- Y / Ar e oTERRY 99. AN EWARR No.38721 100.48 0. v / 99.67 x 99.25 nTOWN OF BARNSTABLE LOCATION 7 Z 9CI ,�Co-�l'�t 6 4 SEWAGE # 2�3 «�,LAGE CO1 r-n Are td C rA nn ASSESSOR'S MAP & LOT-3 5 O°a t INSTALLER'S NAME&PHONE NO. u'A SEPTIC TANK CAPACITY LEACHING FACILITY: (type) Fe-(Cl (size) 3 S. X NO. OF BEDROOMS BUILDER OR OWNER J��n t M4g(re e n PERMTTDATE: . q`Z 3 COMPLIANCE DATE: 1- 2 — Q3 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 i w A w � L w N e N L oco3"— � Fee No. � THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01pprtcation for Mie;pogar *p6tem Con!6truction Permit Application for a Permit to Construct( )Repair( )Upgrad bandon( ) 0 Complete System El Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. 4zs,i R+-.6A - Cww\N\ John 3 atueer 07 Assessor's Map/Parcel S0 D 0`7 Installer' Name, dress,and Tel. o.J� " Design s Name,Addre d e r o. QP��� �� � 'e S , �� Type of Building: Dwelling No.of Bedrooms 4 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 4-4 V gallons per day. Calculated daily flow 2 2 gallons. Plan Date 9— 2-- 3 Number of sheets Revision Date Title s w Size of Septic Tank S pe of S.A.S. 2G`141X,33• ' LXL't Description of Soil. SeeQf m j Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ens a the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions Title-5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been iss d y this Board of Health. Sig Date Application Approved by Date Application Disapproved for the following reasons Permit No. _L00 3 Date Issued 9 d^ O --------------------------------------- I� ' No. / l7 U'°- Fee THE,COMMONWEALTH OF MASSACHUSETTS THE in computer: Je F PUBLIC HEALTH DIVISION -TOWN OP BARNSTABLE, MASSACHUSETTS Yes ZIpprication for Migozar 6p.5teYn;Con.5truction Permit Application for a Permit to Construct( )Repair( )Upgrad Abandon�( ) `❑Complete System ❑Individual Components Location Address or Lot No. ' Owners Name,Address and Tel.No. 42.59 i2t .&A — Cu*-AN� -'ohh s au-f Assessor's Map/Pazcel�SO 0-7 _ G / 2 Installer' Name,Address and Tel. o.S� �3 �� Design 's Name, eS Addre sdJ-e�(l No. , 1 s0� �PeofBilding• y ( q02i4 3 !J&t ,t uxb , 10 0233 Z Dwelling No.of Bedrooms�_ Lot Size / sq.ft. Garbage Grinder( ) " / Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow �D gallons per day. Calculated daily flow J 1L� 2 " gallons. Plan Date S- 12-" 03 Number of sheets Revision Date Title W ( (�a Size of Septic Tank J/( ) 0A D _Sb9ype of S.A.S. &I tOX33.5' Lx4'D OL0..11 1Y/01 Description of Soil See P)t - Nature of Repairs or Alterations(Answer when applicable) Date last inspected: _ Agreement: // ` The undersigned agrees to ensufe the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions gf Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been iss/jd ,ee y this Board of Health_. ned / Sig -J/ Date Application Approved by Date Application Disapproved for the following reasons >a---�.Permit No. .3 Date Issued 9d^ O v --------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CE TIFY,that the On-site Sewage Disposal System Constructed( )Repaired( )Upgraded( ) Abandoned( )by V i 14 c I U01- at y,z Sj C"o v--9 wi A has-been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. ZV Q1d"g28'dated 2-0 3 Installer °` Designer The issuance of Vs ,en-nit shall not be construed as a guarantee that the systems fu o .as de . Date Inspector //---------------------------------------- s. THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Mig;poar *p!5tem Con!5tructfon Permit Permission is hereby granted to Construct( )Repair Upgrade( )Aban n( ) _ System located at Y 5� b fit+ -�'vr~� hn S? 10 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. Prvided: Construction must be completed within three years of the d e of this r• l Date:_ ' c� 4 3 Approvedby _ 1 I nTOWlN OF/ BARNSTABLE LOCATION 7 Z S-q / o�l"Ic b SEWAGE # 2� y� j . VILLAGE Mr,) AG U'C J\ ASSESSOR'S MAP & LOT—3 00 00) INSTALLER'S.NAME&.PHONE NO. �• Ge,(1 14 67 �lA Ott• $3 3�Y r� SEPTIC TANK CAPACITY LEACHING FACILITY. (type) / 1 G�d (size) .3� L NO.OF BEDROOMS BUILDER OR OWNER a�n f �Ai rre e FS r O PERMITDATE: q"Z—D 3 COMPLIANCE DATE: Separation Distance Between the: . Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private' ater 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 1 ' G qra�el. v O . S � A• r. Zs ' �. 1. �2 ' �•� f 2. y3 2,.y , A.� 76- ,6 il y Sq' Y. y3 6 Z .r31y jy/ ' f� 607 00 ? TROY WILLIAMS Ll - 2- SEPTIC INSPECTIONS Certified by MA Department of Environmental Protection � JBJ-1300 19 Hummel Drive , V� South Dennis,XA 02660 ;1, apR1 O COMMONWEALTH OF MASSACHUSETI' O�NOF �ZQ0 tiF a r EXECUTIVE OFFICE OF ENVIRONMENTAL �A�r ATg6�F DEPARTMENT OI, ENVIRONMEN'I'AL PROTEC' N 'FITLE s OFFICIAL INSPECTION FORM NO"T FOR VOT.UNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYS'TF,M FORM PART A CER"TIFICATION Properth Address: 4259 Main Street Cummaquid,MA Owner's Name: Anne&Robert Livermore Owner's Addres,. 4259 Main Street O Cummaquid,MA 02637 0 Date of Inspection: April 12, 2001 O Name of Inspector: Troy M. Williams Company Name: Troy Williams Septic Inspections Mailing Address: 19 Hummel Drive Telephone Number: South Dennis,MA 02660 (508) 385-1300 f CERTIFICATION S'TA1'EMEN'I- 1 certify that 1 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. 1 am a DEP appros ed system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The sv-tern. Passes Conditionall% Passes ` Needs Further I:valuauon b} the Local Approving Authority Fails Inspector's Signature: 'S Date: y//.2 /o t The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Notes and Comments Although system meets the minimum requirements set forth by the Massachusetts Department of Environmental Protection,certification is not to be construed as a guarantee of future working condition of system,piping or components. This inspection represents the conditions of the system on the Date of Inspection noted above. ""`This report only describes conditions at the time of inspection and under the conditions of use at that time. Ihis 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 paee 1 Page 2 of I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) 4259 Main Street Property Address: Cummaquid, MA Owner: Anne&Robert Livermore Date of Inspection: April 12, 2001 Inspection Sdmmary: 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 CNIR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be re aced or repaired. The system, upon completion of the replacement or repair,as approved by the Board of ealth, will pass. Answer yes. no or not determined(Y,N,ND) in the for the following statements. I not determined"please explain. The septic tank is metal and over 20 years old* or the septic tank(whe er metal or not)is structurally unsound. exhibits substantial infiltration or exfiltration or tank failure is i inent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by t Board of health. "A metal septic tank will pass inspection if it is structurally sound, t leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. v ND explain: Observation of sewage backup or break ou r high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or even distribution box. System will pass inspection if(with approval of Board of Health): bro n pipe(s)are replaced struction is removed distribution box is leveled or replaced ND explain: The system quired pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection ' with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of 1 I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 4259 Main Street Cummaquid,MA Owner: Acme&Robert Livermore Date of Inspection: April 12, 2001 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 'f 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 CM 5.303(1)(b)that the system is not functioning in a manner which will protect public health,safety d 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 o a salt marsh 2. System will fail unless the Board of Health and Publi ater Supplier,if any)determines that the system is functioning in a manner that protects the pub ' health,safety and environment: _ The system has a septic tank and soil absorp 'on system (SAS)and the SAS is within 100 feet of a surface %rater supply or tributary to a surface % ter supply. _ The system has a septic tank and S and the SAS is within a Zone 1 of a public water supply. The system has a septic tank d SAS and the SAS is %%ithin 50 feet of a private water supply well. _ The system has a septic ank 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 pass if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and vol a organic compounds indicates that the well is free from pollution from that facility and the presence ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure cri is are triggered.A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) 4259 Main Street Property Address: Cummaquid,MA Anne&Robert Livermore Owner: April 12, 2001 Date of Inspection: 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 c10e2ed 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. AdA Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. AiLq Any portion of a cesspool or privy is within a Zone 1 of a public well. N d Any portion of a cesspool or privy is within 50.feet of a private water supply well. N� Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supple well with no acceptable eater 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.) go _(Yes/No)The system fails. l have deterntined that one or more of the above failure criteria exist as de�crihed 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 desi 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 criteri bove) yes no the system is within 400 feet of a surface drinking ater supply the system is within 200 feet of a tributary t surface drinking water supply the system is located in a nitrogen se tive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone 11 of a public water supply 1 If you have answered"yes"to any q tion in Section E the system is considered a significant threat,or answered "yes" in Section D above the larg ystem has failed.The owner or operator of any large system considered a significant threat under Sectio or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner ould contact the appropriate regional office of the Department. 4 Page 5 of 1 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 4259 Main Street Cummaquid, MA Owner: Anne&Robert Livermore Date of Inspection: April 12, 2001 Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No information was provided by the owner. occupant. or Buar,1 of I Lakl, _✓ 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? _vl 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: 4259 Main Street Cummaquid, MA Owner: Anne&Robert Livermore Date of inspection: April 12, 2001 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 5 Number of bedrooms(actual): _jy DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): . 5 5 ti Number of current residents: Does residence have a garbage grinder(yes or no): Y67 S Is laundn on a separate sewage system (yes or n l:nio [if yes separate inspection required] Laundry system inspected(yes or no): NIA Seasonal use: (yes or no):_o Water meter readings, if available(last 2 years)jsage(gpd)): Oa = 83 DDy a ;/� `/5 o0 0 uilo�. Sump pump(yes or no): YF 5 '�`— i } Last date of occupancy: c L COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gp i 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 s em (yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Was system pumped as pan of the inspection(yes or no): /vo 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: /27 /1 / n..- As - b„ It Were sewage odors detected when arriving at the site(yes or no):1ua 6 Page 7 of I I OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 4259 Main Street Cummaquid,MA Owner: Anne&Robert Livermore Date of Inspection: April 12, 2001 BUILDING SEWER(locate on site plan) Depth belu�k grade: /8 4- Materials of construction: _cast iron 40 PVC_other(explain): Dktinc:• from pirate water supply well or suction line: Comments(on condition of joints, venting,evidence/of leakage,etc.): Ti,c YI-a.t o I� _ SEPTIC TANK: ✓(locate on site plan) Depth below grade: I " Material of construction: Acincrete_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: ,X �U 'x /5v U y .11.1,. Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: .2 ` y Scum thickness: No-,y Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: No s How were dimensions determined: Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): i r ^ ��• ) /C1�_ / (�:� � 1...+it 1 ya a f ✓� 0`T v YY� r.y G.l 71. GREASE TRAP:_(locate on site plan) Depth below grade: Material of construction:_concrete_metal_fiberglass_po ethylene_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 to r baffle: Date of last pumping: Comments(on pumping recommendations, in and.outlet tee or baffle condition, structural integrity,liquid levels as related to outlet invert,evidence of leak e,etc.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 4259 Main Street Cummaquid,MA Owner: Anne&Robert Livermore Date of Inspection: April 12, 2001 TIGHT or HOLDING TANK: (tank must be pumped at time of ins ction)(locate on site plan) Depth belo",grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity: gallons Design Flo\ gallons/day Alarm present(yes or no): Alarm level: Alarm in working or (yes or no): Date of last pumping: Comments(condition of alarm and fl switches, etc.): DISTRIBUTION BOX: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover, any evidence of leakage into or out of box, etc.): 11 1 -L J C I ✓ i� e V A < � t�©I ok ct y u✓t✓ PUMP CHAMBER: (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,conditio of pumps and appurtenances, etc.): 8 Page 9 of 1 I OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 4259 Main Street Cutnmaquid,MA Owner: Anne&Robert Livermore Date of Inspection: April 12, 2001 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: 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.): tick C�< c{ti<d( , c o , .A NJ 4 r. `t Q�'V Ga,}�4 GV` WL.I/✓-. i'� CESSPOOLS: (cesspool must be pumped as pan of inspection)(loc a 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): Comments(note condition of soil,signs of by aulic 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 f ' re, level of ponding,condition of vegetation,etc.): 9 Page 10 of I I OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 4259 Main Street Property Address: Cummaquid,MA Anne&Robert Livermore Owner: April 12, 2001 Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. * I• -� a t. . s; d 6 A c = W L� c. - 32 30 60 a F = 1.i h h V, So ' y z te 10 'Page I 1 of OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 4259 Main Street Cummaquid,MA Owner: Anise&Robert Livermore Date of Inspection: April 12, 2001 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 134 feet Adjusted high ground water elevation — feet Please indicate(check)all methods used to determine the high ground �►ater 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) 51-p, Checked with local Board of Health-explain: Checked with local excavators, installers-(attach documentation) . Accessed USGS database-explain:6 i w -JLy 7 2 , You must describe how you established the high ground water elevation: 'A rcc .A a l 2 'r 7 4 n.� ✓l i r-->3 /' J, 30 0— ., t / 7 /e r... J 11 I (09 FAILED INSPECTION COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS I I UVII DEPARTMENT OF ENVIRONMENTAL PROTECTION RECEIVE JUL 15 2003 TOWN OF BARNSTABLE. TITLE 5 HEALTH DEPT. OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 4259 Main Street, Route 6A Barnstable, MA 02630 Owner's Name: John&Maureen Sproha Owner's Address: P.O. Box 655 Barnstable, MA 02630 Date of Inspection: July 7, 2063 Name of Inspector: (Please Print) James M. Ford Company Name: James M. Ford Map:350 Mailing Address: P.O. Box 49 Parcel. 007 Ostervllle,MA 02655-0049 Lot: 1 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 Further Evaluation by the Local Approving Authority ✓ Fai Inspector's Signature: nacop � Date: July 13, 2003 The system inspector shall sub,-. of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design,flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. 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 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTWICATION (continued) Property Address: 4259 Main Street, Route 6A Barnstable, MA Owner: John&Maureen Sproha Date of Inspection: July 7, 2003 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: 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: 4259 Main Street, Route 6A Barnstable, AM Owner: John&Maureen Snroha Date of Inspection: July 7, 2003 C. Further Evaluation is Required by the Board of Health: _ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has aseptic 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: 4259 Main Street, Route 6A Barnstable, MA Owner: John&Maureen Snroha Date of Inspection: July 7. 2003 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 '/2 day flow ✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_. ✓ Any portion of the 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 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.] Yes (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 hPd• 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 Page 5 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 4259 Main Street, Route 6A Barnstable, MA Owner: John&Maureen Sproha Date of Inspection: July 7, 2003 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: 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)]. I 5 Page 6 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 4259 Main Street, Route 6A Barnstable, MA Owner: John&Maureen Sproha Date of Inspection: July 7, 2003 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 Number of current residents: 2 Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system(yes or no): No [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: Currently occupied COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): pd 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): t GENERAL INFORMATION Pumping Records Source of information: Pumped 1 month azo 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: Jun. 27191 per as built card Were sewage odors detected when arriving at the site(yes or no): No 6 r Page 7 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 4259 Main Street, Route 6A Barnstable, AM Owner: John&Maureen Sproha Date of Inspection: July 7, 2003 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: 2' 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: 1500 gal. Sludge depth: 0" Distance from top of sludge to bottom of outlet tee or baffle: -- Scum thickness: 0" Distance from top of sum to top of outlet tee or baffle: -- Distance from bottom of scum to bottom of outlet tee or baffle: -- How were dimensions determined: Measuring stick Comments(on pumping recommendations,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 up to the outlet invert. Solids were above the tees 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: Date 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.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM_ INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 4259 Main Street,.Route 6A Barnstable, MA Owner: John&Maureen&roha Date of Inspection: July, 7, 2003 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 Alarm 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: Above 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.): Liquid was above the outlet pipe. 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.): I 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: 4259 Main Street, Route 6A Barnstable, MA Owner: John&Maureen Sproha Date of Inspection: July 7, 2003 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: ✓ leaching chambers,number: 5-flow diffusors 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 liquid was above the inlet pipe and up to the top of the chambers: Liquid was backing up into the D-box. The leaching chambers were in failure. 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): Comments (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 Page 10 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 4259 Main Street Route 6A Barnstable MA Owner: John&M_ crureen Sproha Date of Inspection: July 7. 2003 Map:350 SKETCH OF SEWAGE DISPOSAL SYSTEM Parcel: 007 Provide a sketch of the sewage disposal Lot: 1 S p 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 4. 4A�k O �y 3a o a a �o Yo 3 � So ya M 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: 4259 Main Street, Route 6A Barnstable, MA Owner: John&Maureen Sproha Date of Inspection: July 7, 2003 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 30 +/- 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: topographic and water contours maps Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Using the Barnstable topographic map and the Cape Cod Commission water contours map the maps were showing approximately 30'+/-to ground water at this site. This report has been prepared and the system inspected and failed 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 system, the inspection and/or this report. 11 " ASSESSORS MAP: 350 TEST HOLE LOGSNOTES: PARCEL: Wl �00 I ��a,s.1 -(� SOIL EVALUATOR: D. Nekje_! . ?.S.r C5e TDATUM: I FLOOD ZO E• 1. VERTICAL `�t/Mt� 100.75 WITNESS: `�°T Rev+�� REFERENC : uP/3/217 \ 2. MUNICIPAL WATER �� AVAILABLE. DATE: UL- + 3 3. SCHEDULE 40 PVC PIPE TO BE USED THROUGHOUT SYSTEM UNLESS PERCOLATION RATE: paI51EVC h0k 1S D OTHERWISE NOTED. Ea9P PKtSETo.00 0028 70- �=L-fAR + 0. C. l y � s�F"( ST_rp� 6y 4. ALL PRECAST UNITS TO CONFORM WITH AASHT❑: ��U O UP / 18 011 TH-1 JR. TH-2 5. PIPE PITCH - 1/4' PER FOOT UNLESS OTHERWISE NOTED. 01111 x 1 0.39 100.19 "A S 6. ALL CONSTRUCTION DETAILS TO BE IN CONFORMANCE WITH MA. ENVIRONMENTAL LOCATION MAP �rl T-5, D �� ,8 uM l�y,�s� 95'1y n'l CODE (TITLE V) AND 'LOCAL REGULATIONS. UT 7 IV! A 7. CONTRACTOR TO VERIFY LOCATIONS OF ALL UTILITIES PRIOR TO CONSTRUCTION. ,IC, '� 6' LOAM , N 6, 99.90 76N ,Arty ����s�3 F-66P A4 Ge 1 1r, i3 P ^'�QED/.G1�U�? � !L _�_.._p ip / 00- U.2 0.61 1, ..0,9 99.86 S 1 ur I U� pro P�� U A _ DO C LURM L ryS�3 q- _Nb UAWtJ WeTL/1MD5 win l C� 101.15 / �vI 0 6 ® CB/DH/FN99.72 ►q2" $0,57 l0• P 9W0wnJ PR-1 U4--� wt,.�---w1 iN 66 OF PP-0 P05E D �t+mJ • ,� 07 101.54 10# 99.61 C3 S I �' $ ALL UNSU ll A aLE 701(- -1-09E ReWtjf o 5 �4Rovm o �/fH-1 N � l --- l01 o Z4b. 76.57 OIL.- Top or- C � rt.- Rep U7 C 100.40 / WE,EPIMN t�OE /UZ (EL.&DD T x 99.40 ��' / TI 11;E SEPTIC SYSTEM DESIGN D ck Bk 100.74 Benchmark set t FL11W ESTIMATE q Right corner w bottom step 3 #4259 Et.=101.40 Q l _� BEDROOMS AT GAL/DAY/BEDROOM = yqb TDF=102.27 100.8a (Assumed) (Assumed) EpsriNC J 99.41 GAL/DAY 4 5uu GAl SEP; TIC TANK a 'llkf k c/ 101.74 .76 y� � GAL/DAY x 2 DAYS = bgo SE TIC/ D 99.80xIF GAL 101.89 P tl �- ti us- GALLON SEPTIC TANK- EX►STING :x 100.2a ��~► :L l e SO!,_- ABSORPTION SYSTEM L S h k1�•,�- 101. 10 .02 Deck T 54 33_S I L >< G ,I LE,4Cf1 Fl EL p A AT N 10.18 x 4 (, E!?A1, 5 f� - _ SIDE AREA: g 102.0a BOTTOM AREA: 33,Sx ZO x U•66qW. �i 102.73 101.8 BRCK PED36 �7 7d r�f�() yP�;�I 02.77 102.52 x /..7 101.5 SEPTIC SYSTEM SECTION 0 10 87 110 LY 0101.16 -Zl7NECCIV 100,44 x x 1 To El.. $D. Garage � U� T-0P U� _� - -• l00 - q� �_►1: o ��SLAe) x x 3PD. C3 c Ay�� �� $Rinlcl Coves w',h 9hir �W .`L o 9A 8FT-DIAMR E2<�ST7 �0' I v 6„0� �n�Sh�fAalf ZIEL M4u a6k 41,.96.50 h 101.2 / ...,. 6. 100.88 / TP / g1O.93 Bf1FAGE ELEV 6'S�ne WAS � S�o,vE .33 ELEV D-BOX � 33 �S.t,�' 1 " 5 /S► ti �K / 5 GAL 1 Sp ELEV 33.5LXZo w Stone 20 " Q, . /,� rill Fe�J SEPTIC TANK ELEV jky /tve/y�SS Parking 81 a -OoF �1C1ST//1� Area 100 4IN- v ERRTY 99. ANN WARNER OF MA SITE AND SEWAGE PLAN 100.48 W.33721 N t LOCATION: �{259 F0Ul-E 6A No 1140 CUM104QUID MA 99.67 666 ISTE -, MAuE��� SP �f� x 99.25 3 S41VITAR\PN ` PREPARED FOR: 7onl �b (3 98.03A •fib N 1 •, w Sca t e: 1'=20' � SCALE: x 98.61 0' 20' 40' 60' DARREN MEYER, R.S. DATE: f2'03 43 VINE ST. / DUXBURY, MA 02332 DATE HEALTH AGENT (508)362-2922