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0221 OLD JAIL LANE - Health
. . . . •le 1 1 9 iYa P' TOWN OF BARNSTABLE LOCATION 1 lJ +� cculi— SEWAr.9# 6 SP VILLAGE )51,r n Sd�,,bl.ft- ASSESSOR'S MAP&PARCEL IN9TPMt R'S NAME&PHONE NO. k ru 11 SEPTIC TANK CAPACITY J 0W LEACHING FACILITY.(type) jQGO !JcJ P�} 4 0P44 (size) NO.OF BEDROOMS q OWNER PERMIT DATE: @6W-ftANCE DATE:::T,. O B . 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 leachin facility) Feet FURNISHED BY - 6 f \•\•\•\. \.\, .\.�.\.\.\.\.\. .\. .\.\.\.\. fyf l4f \ k \ \ \ ..\ \..\..1 \ \ \+.tip\'-.\ .•� f J f F J ! f 2 1'6 47' 38 �> 42: 40 `- Coltiimonwealth of Massachusetts u Aibn� F®r Title Official lns ec �. m Not for Voluntary Assessments a Subsurface Sewage Disposal.System,Form - I V 221 Old Jail Lane. Fr � Property Address John &Julie Willis Owner Owner's Name information is Barnstable MA '02630. May-6 2009 required for State Zip Code Date of Inspection every page. Cityrrown Inspection results must be submitted on this form. Inspection forms may not be altered in any way: %. Important: A. General Information When filling out forms on the computer,use 1. Inspector: _ only the tab'key to move your Patrick M. O'Connell cursor-do not Name of Inspector use the return key. Septic Inspection Services Co. Company Name 189 Cammett Road Company Address Marstons Mills MA m .`02648 renm Oity/Town State Zip Code 508-428-1779 . SI 12855 Telephone Number- License Number B. Certification. { I certify that-I have personally inspected the,sewage disposal system at thisaddress and that the: 'R information reported below'is true., accurate and;complete as of the tirne'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 ❑ Fall ElNeeds Further Evaiva.tion by.the Local Approving P.u.thority ':. r Ma 6,,2009 t t r;o6 ( �. .. Ins ctor's Signature Date .. l` rD ti r The system inspector shall submit a copy of this inspection report to the Approvin 'Authority (Board of Health or DEP)within 30_days of completing this inspection. lf.the system is a s ared 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 09-74 Wdlis.doc•08106 Title 5 official inspe ction Form:Subsurface Sewa a isposal,system:Page 1 of 15 Commonwealth of"Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form. Not for Voluntary Assessments 221 Old Jail Lane Property Address John &Julie Willis Owner Owner's Name information is Barnstable MA 02630 May 6, 2009 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont:) Inspection Sumrnary:'Check-A,B,C,D or 7 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 , 4% Comments: Tank was pumped following inspection leaching'system`shows no evidence of saturation. B) System Conditionally Passes: t v❑ One or more system`.compo.nents 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 ❑Pfor the following statements. If'not determined," please explain.' Fj The septic tan,k.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 than20 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 09-74 Wdtis.doc•08/06, - _ _ Title 5 Official.Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 Commonwealth of Massachusetts W Title 5 Official Inspecti®n Form Subsurface Sewage Disposal System Form =Not for Voluntary Assessments 221 Old Jail Lane Property Address John &Julie Willis Owner Owner's Name information is required for Barnstable MA 02630 May 6, 2009 every P 9 e.a City/Town State Zip.Code Date of Inspection ., B. Certification.(cont.) . B) System Conditionally.Passes (cont.): ❑ 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; , C) Further Evaluation is Required by the Board-of Health: 7 Conditions existwhich`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: ElCesspool 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.ta'a surface water supply., ❑_ The system hata`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.. 09-74 Willis.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of.15 Commonwealth of Massachusetts Title 5 Official Lnspe�..ti®n Fori�i Subsurface Sewage Disposal System Form Not for Voluntary Assessments 221 Old Jail Lone.. Property Address John &Julie Willis Owner Owner's Name �. r information is gamstable MA 02630. May 6, 2009 required for every page. Cityrrown State Zip Code • Date of Inspection„ B. Certification (cont.) C): Further Evaluation is Required by.the Board of Health (cont.): ❑ The system has:a`septic tank and,SAS and`the'SAS is Iess than .1 00.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 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 pondN 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 cloggedSAS or cesspool .: Liquid depth in cesspool is less than 6" below 'invert or available volume is less El ® than day flow Required pumping more than 4aimes in the last`year-NOT due.to clogged or, ` ® obstructed pipe(s)._Number ofaimes pumped: ❑ ® , Any portion.of the SA:>,�cesspool or privy is below-hi of elevation El. ® Any portion'of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water.supply. 09-74 willis.doc•08/05 Title 5 official Inspection Form:Subsurface Sewage 0isp8sat System•Page 4 of 15 } Commonwealth of'Massa'chusetts Title 5 Official Inspection Form 1 _ Subsurface Sewage Disposal System form.- Not for.Voluntary Assessments. 221 Old Jail Lane Property Address John & Julie Willis Owner Owner's Name information is Barnstable MA? 02630- May 6, 2009 required for y every page. City.Town State Zip Code -Date of Inspection " B. Certification (cont.) D) System Failure.Criteria Applicable to All Systems (cont.):ry Yes. No \❑ ® 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 . . ❑_ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet p. .;from a private watersupply`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 ess than 6 ppm, provided that no other failure criteria are triggered. A copy,of the analysis x 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 CMF,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. ) design low of :O o d g y y erve,a facility with a E .Large Systems: To be considered a large system the system must s 9 gp 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;sys'tem is within 200 feet of a tributary to a surface drinking water supply a the'system is located in a`nitrogen sensitive.area (Interim Wellhead Protection Area IWPA) or a'mapped Zone Il:of a public water supply well , 1f 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. 11 09-74 Willis.doc•08/06 Title 5 Official'Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15. I Commonwealth of.Massachusetts W Title 5 Official° Inspection Forim Subsurface Sewage Disposal System Form- Not for Voluntary.Assessments M 221 Old Jail Lane Property Address John &Julie Willis Owner Owner's Name information is required for Barnstable MA 02630 May 6, 2009 ` , every page. CityTown 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 theprevious two weeks? ❑ Has the system.received normal flows inthe previous two week,period? ❑ ® Have large volumes of water been introduced to the'system recently,or as part of this inspection? Were as plans of the system:obtained�and examiried? (If they were not ® ❑ available.note as N/A) ® ❑ Was fhe.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�bbcupants if different from owner) provided with information on the maintenance of subsurface sewage disposal systems? proper 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)] , 09-74 wllis.cloc•08/06 Title 5 official Inspection Form:Subsurface Sewage Disposal.Syslem.-Page 6 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Forim Subsurface Sewage Disposal System Form Not for Voluntary Assessments 221 Old Jail Lane Property Address John & Julie Willis Owner Owner's Name information is Barnstable MA 02630 May 6; 2009 required for every page, City/Town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 4, Number of bedrooms (actual): '3 DESIGN flow based on 310:CMR 15.203 (for example: 110-gpd- #of bedrooms):_ 440 Number of current residents. 5: Does residence have a.garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑' .Yes ® No Laundry.system inspected?; ❑, Yes ❑ No . Seasonal use?' ❑ Yes ® . No N/A-Well Water Water meter readings, if available'(last 2 years'usage (gpd)):` Sump pump? ' ❑ Yes ®. No Currently a Last date of.occupancy: Occupied Commercial/Industrial Flow Conditions:. Type of Establishment:' Design flow (based on 310 CMR.1.5'.203): ' Gallons per day(gpd) Basis of design:flow (seats/persons/sq:ft., etc.):' Grease trap present? ❑ Yes ❑ No , _ . . -Industrial•waste holding tank present? El Yes ❑ .No Non-sanitary waste discharged_to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of,occupancy/use: Date Other(describe): 09-74 Willis.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 Commonwealth of Massachusetts _ _ Title 5 Official Inspection FOrrn Subsurface Sewage'Disposal System Form = Not for Voluntary Assessments. 221 Old Jail Lane Property Address ;John &Julie Willis Owner Owner's Name' information is Barnstable MA 02630, May 6, 2009 required for every page. City/Town State Zip Code Date of Inspection' D. System Information'(cont General Information Pumping Records: Source of information: Tank pumped three years agog Was,system pumped as part of the inspection? a 4 - El Yes ® No " If yes, volume pumped:. gallons How.was quantity pumped'determined? Reason for pumping: Type of System:' ® Septic"tank;'distribution boz,•:soil absorption system Single'cesspcol El 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. a` Original system installed in 1987 leaching trenched added in 1995.. Were'sewage odors detected when arriving at the site? ❑ Yes ® No 09-74 Willis.doc•.08I06' - -- Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 8 of 15 Y ° Commonwealth "of Massachusetts Title 5 Official Inspecti®n Form' Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w 221 Old Jail.Lane Property Address John &Julie Willis Owner Owner's Name , information is required for Barnstable oMA 02630, ' May 6, 2009 - , every page. CitylTown State Zip Code Date of Inspection D.. System. Iniiormation (cost.) Building.Sewer(locate on site plan): Depth below grade: feet Material of construction` ❑bast"ron_ . ® 40 PVC ❑ other(explain):. Distance'from private water.supply well or suction line:' feet Comments (on condition of joints, venting, evidence of leakage, etc.): n .. Septic Tank (locate on site plan): V. Depth below grade:,. feet ' Material of construction: ® concrete El metal ❑ fiberglass- ❑ polyethylene El other(explain). If tank is metal,.list age:. years Is age confirmed by Certificate of Compliance? (attac.h.a copy of certificate) ❑ Yes ❑ No - ----- -- - 8.5';long x 52 wide- 1000 gal. Dimensions: ' 4„ Sludge depth: Dlstance,from top of.sludge to bottom.of outlet the or baffle 26 x 3" Scum,thickness Distance from top of scum to top of"outlet teefor baffle11 Distance'from bottom of scum to bottom of outlet tee.or baffle 10 How were dimensions determined? Measured 09-74 Willis.doc•08/06 Title 5.0fficial Inspection form:Subsurface Sewage Disposal System•Page 9 of 15 Commonwealth of Massachusetts w W Title 5 Official Inspection ForM Subsurface Sewage Disposal System Form - Not,for Voluntary Assessments . 221 Old Jail Lane Property Address John & Julie Willis Owner Owner's Name information is Barnstable MA 02630 May required for Y 6, 2009 every page. City/Town 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,):. Liquid level was found at bottom of outlet invert, tees are intact and clear. Tank was scheduled to be pumped following inspection. - Grease Trap (locate on site:plan):' r Depth below.grade: Jfeet Material:of construction: [:]'concrete ❑ metal g ❑.polyethylene, ❑ other(explain): ❑ fiber lass. Dimensions: { Scum thickness Distance from top of scum to top of outlet tee or"baffle , Distance from bottom.of scum to bottom of outlet tee or baffle Date of last pumping: Date' Comments(on pumping recommendations, inlet and outlet tee.or baffle condition, structural integrity, . liquid levels as related to outlet invert, evidence of leakage,.etc.): Tight or Holding Tank (tank..must be pumped at time of inspection),(Locate on site plan) Depth below grade: Material of construction:. ❑ concrefe ❑ metal ❑ fiberglass 0 polyethylene ❑ other(explain) 09-74 wiillis.doc•08/06 - - - - Title 5 Official-Inspection-Form:Subsurface Sewage Disposal System•Page�10 of.15 Commonwealth & Massachusetts ` N Titlel 5 Official ci a In s ection Fora Subsurface Sewage Disposal System Form Not for Voluntary Assessments 221 Old Jail Lane { ` . .Property Address John &Julie Willis Owner Owner's Name . information is Barnstable required for MA 02630 May 6, 2009 every page. City/Town State' Zip Code Date of Inspection D. System Information (cont.) Tight or Tank (cont.) Dimensions' . Capacity: ? gallons. Design Flow:' gallons per day Alarm,present; E,a Yes ❑ ,No Alarm level: .Alarm in working order: . . ❑ Yes ❑ No Date of last pumping: Rate Comments (condition of alarm and float switches, etc.): ' *Attach copy of current pumping.contract(required). Is copy attached? ❑2:Yes ❑ No Distribution Box'(if present must be opened) (locate on site pIan):- 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.): No'solids or high stains'present. • l r Pump Chaim ber(locate on site plan) Pumps in working order: Yes, ❑ No Alarms in working order ❑ Yes- ❑ No 09 74 wilfis.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System,•Page.11 of 15 v r, Commonwealth & Massachusetts Title 5 Official Ins eCtion For* m p' Subsurface Sewage Disposal System Form = Not for Voluntary Assessments e 221 Old Jail Lane Property Address i John & Julie Willis Owner Owner's Name information is Barnstable required for MA 02630 May 6, 2009 every page. City/Town State Zip Code Date of Inspection D. System Information .(cont.) w Comments (note condition of pump chamber, condition of.pumps and appurtenances, etc.): Soil Absorption System.(SAS) (locate on site plan, excavation not required): if SAS not located,,explain why: I. Type: i. x It: ,e`6 6 ® _ leaching pits number: On p ❑ leaching chambers ' number. F ❑ leaching galleries number.. ® leaching trenches - number, length. : Two 38',trenches ❑ leaching fields number, dimensions. s „ ❑ overflow cesspool number. y: ❑ 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.): . - < 4 Trenches were probed and no signs of'saturation Were found leaching pit and trenches.show no evidence of surcharge: ,t. 09-74 Willis.tloc•08/06 Title 5 Official inspection Form_Subsurface Sewage Disposal System•Page 12 of 15 `Commonwealth.of Massachusetts N Title 5 0►fficial . Inspecti®n Form Subsurface Sewage Disposal System Form - Not for,Voluntary,Assessm,ents ^M 221 Old Jail Lane • Property Address John&Julie Willis Owner Owner's Name information is required for Barnstable MA 02630, May 6, 2009 every page. CityTown State _ Zip Code,* Date of Inspection„ D. System Information (cont.) Cesspools (cesspool.must be pure ed;as part of inspection) (locate on site plan):'' . Number and configuration Depth—.,top of liquid to inlet invert i Depth of solids layer' Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater.inflow ED "Yes Comments (note condition of soil, signs of hydraulic failure, level of ppnd,ing, condition of vegetation,, • etc:): Privy (locate on:site:plan):.. Materials of construction. J, Dimensions Depth of solids . Comments.(note condition of soil, signs of hydraulic failure level of.ponding, condition of vegetation, etc.): I : 0 9-74 Willis.doc•08/06 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 13 of 75 ?. Commonwealth of Massachusetts Title 5 Official Inspecti®n F®rrr Subsurface Sewage Disposal System'Form -Not for Voluntary Assessments' ' r 221 Old Jail Lane :Property Address John &.Julie Willis Owner -- ------ - __ __ , Owner's Name information is y , required for Barnstable w . MA 02630 May 6 2009 _ every page: City/Town State Zip Code Date of Inspection D. System Information (cost.)'' • 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. 2 16 I 47 P , 42 .30 6 .. .." 40 - 17 a_ .a a� r i { ' Commonwealth of Massachusetts Title 5 Official InSpecti®n ®rrn Subsurface Sewage Disposal System Form .Not for Voluntary Assessments 221 Old Jail Lane Property Address John &Julie Willis Owner Owner's Name information is Barnstable required for _ MA 02630 May 6,2009 every page. CltylTown.. Sate Zip Code Date of Inspection D. System Information (cont.) Site Exam:. ® Check Slope ® Surface water ® Check cellar ® Shallow wells 30 Estimated depth to ground water: - feet -Please indicate all methods used to determine the high ground water elevation::. k: t ❑ 'Obtained from system design plans on record Ifichecked; date of design plan reviewed: pate i I'. ® Observed site (abutting property/observation hole within 150.feet of SAS) . ❑ Checked with local Board of Health- explain: , e - ❑ Checked with Jocal,excavators, installers -,(attach documentation) l' ❑ Accessed USGS database--explain- - �r You must describe how you established the high ground water elevation: r. Low.point at front of p'roperty,is considerably lower than SAS. w F ~: „ n "09-74 Willis doc•08106 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 15 1 TOWN OF BARNSTABLE I; A ON 22I 0.1Z ZW �/i: �Cl�✓F7`!l&WAGE VILLAGE ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. / Ir SEPTIC TANK CAPACITY `✓�®® LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUILDER O 0 / PERMTTDATE: 3 .a� COMPLIANCE DATE: 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 G� W cask r . . a TOWN OF BARNST..1ABLE LOCATION KJ SEWAGE # VILLAGE �����s9 ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) �7+ (size) NO.OF BEDROOMS BUILDER OR OWNER l tv 2 PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 fee f le hin facility) Feet Furnished I �x�,�' —,, �- � 1 �: ,\ <�� ��.�J - _ �, , ��� �� \ � � f - �- -. r No. Ud — O. Fee s THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ' Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 2pplication for ;Di!6poga1 *p5tem Conaruction Permit Application for a Permit to Construct(✓)Repair( j Upgrade( ;Abandon( ) LJ"Complete System Individual Components Location Address or Lot No, Owner's Name,Address and Tel.No. Assessor's Map/Parcel 1a01fe,57a'lvlle Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size Ef sq.ft. Garbage Grinder(X-0 Other Type of Building G &— No.of Persons Showers( ) Cafeteria( ) Other Fixtures e ie — Design Flow gallons per day. Calculated daily flow 2 `7'7 _ gallons. 17 Plan Date /// e , Number of sheets / Revision Date J A? _ Title 45 J �fi' V Size of Septic Tank /��1� 9 '� Type of S.A.S. Description of Soil ''�s ��-�✓r` /�a � Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued b is oar f Health. / Signed e Date all.I Application Approved by Date G Application Disapproved for<e following reasons Permit No. a 0 0 tl 0 b Date Issued ;X D "' Y M Fee;• 4A,._ THE COMMONWEALTH OF MASSACHUSETTS Entered m computer. Y�/'^. es PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS� - 2pplication for Migonl *pgtemc Congtruction Permit Application for a Permit to Construct(✓)Repair( )Upgrade( )Abandon( ) R Complete System 0 individual Components Location Address or Lot No. o z Owner's Name,Address and Tel.No.zi 1�r�i/ /�: fv/ Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. T 2 0 Type of Building: 1 r Dwelling No.of Bedrooms 2 Lot Size �� z 7� sq.ft. Garbage Grinder(/C05 Other Type of Building 61^1"sf e No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow Z z©' gallons per day. Calculated daily flow yz -gallons. Plan Date ZI t�1V Number of sheets / Revision Date 12,9 leo z/ Title r Size of Septic Tank /dDD ! V/ Type of S.A.S. / — tea'�Q (' Des 7e Description of Soil f 10.15_Xel S-3 -r"aip G Nature of Repairs or Alterations(Answer when applicable) ` g , Date last inspected, Agreement: S The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Board of He lth. Signed i� Date Application Approved by Date G L� Application Disapproved for a following reasons Permit No. U 0 s(_ov) Date Issued r THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed(✓)Repaired( ' )Upgraded( ) Abandoned( )by / �✓�/� . / �._�D f� S , � at 27 i2/.�51 r� j �(y''/`il sly �P has been constructed,in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. jo�l-�i�U dated 3�a G Installer Designer The issuance of this permit shall not be construed as a guarantee that the S%em will function -desi . ed. Date �i Zci l b j . Inspector d No. b o q -tso Fee /a U THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Migooal pgtem Con!5truction Permit Permission is hereby granted to Construct(✓)Repair )Upgrade( )Abandon( ) System located at Z and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Constrilction must be completed within three years of the date of tl,� ernu Date: I o2ZOV ApP roved by r TOWN OF BARNSTABLE 6 LOCATION Z J ®�`� ✓��/ AGE # -�fsD VILLAGE ��5/ '!� ASSESSOR'S MAP &LOT INSTALLER'S NAME&PHONE NO. ��`v''/ w ' SEPTIC TANK CAPACITY .Oaa -------------- LEACHING FACILITY: (type) `�`�®� a��- (size) I NO. OF BEDROOMS / / BUILDER 0T(01 PERMTTDATE: �/Z O COMPLIANCE DATE: Separation Distance Between the: ' Maximum Adjusted Groundwater-Tibleto the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist Feet on site or within 200.feet of leaching facility) Edge of Wetland and Leaching Facility(If any wetlands exist Feet within 300 feet of leaching facility) Furnished by G 6a�`a9e, z .. B 6 » h2 - 3 G 3 -/4 �6 �� • tel.(508)362-4541 •939 main street rt 6a fax(508)362-9880 yarmouth port mass 02675 down cape engineering civil engineers& land surveyors structural design Arne H.Ojala P.E.,P.L.S. Daniel A.Ojala, P.L.S. land court Timothy H.Covell,P.L.S. surveys March 31, 2004 site planning Thomas McKean, RS sewage system Director, Barnstable Health. Department designs 200 Main Street Hyannis, MA 02601. inspections ,,Re: 221 'Old,,Jail Lane, Barnstable permits r` Dear Tom: On or about March 22, 2004, Down Cape, Engineeriing, Inc. _ performed a soils removal inspectipri- as required;• on the. approved plan at the above-referenced location. a This is to certify that the soils removal was completed satisfactorily. If you have any questions, please do not hesitate to call me. Yours truly, 46 Arne H.. Ojala, ,,PE, PLS Dowri •Cape Engineering, ;Inc. cc: Bortolotti Construction f Town of Barnstable Regulatory Services • MUMSTABLE. 9 a s6s9. Thomas F. Geiler, Director �p `0m 'ED1AP`' Public Health Division Thomas McKean, Director 200 Main Street,Hyannis;MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Designer Certification Form Date: Designer: Address: 1W g t�„ -r— On A_L, Q� ' s, , issued a permit to install a (dat (installer) septic system at a�� Jc r,---q-44--r based on a design I drew, (address) dated �ZY16 9 I certify that the septic system referenced above was installed according to the design. substantially I certify that the septic system referenced above was installed with "changes but in accordance with State & Local Regulations. Revision or certified as-built by designer to follow. H OF 414Ss9c �o ARNE H. yc a OJALA CIVIL v No. 2 (Designer's Signa • w.a e) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q:Health/Septic/Designer Certification Form C C r3u V'cv w fl L CIO ^1 St. , \t.t �y � � � � ra. ur'• S 8405 T9'E j ._--- '-- ---—.Bu�7dti 9�,emve(sre nro Ts _.16_4' opased Gore _ I. 1 Utility W I Soya - ice/ J• III � ~ � � ' 2 st.y j wood a-fiMg (q I (comp.uadal - �j N 1221 I t\ 3� N 3 Locus Map I , I \ I ASSESSORS REF.: ZONE: —_--__ Light Poste / p�I j Map 278, Parcel 50 RC j Lot I41 I Area(a l5) 00 SF 1 i i W 1 3 OVERLAY DISTRICT: Francagqe�mrn) 20 ' I O Width(min) 200' AP— Aquifer Protection District I.E.kKs: d' - As Shown on Plan Entitled Front 30' S I OI' Revised Groundwater Protection Side 15' Overlay Districts'— April, 1993 Rear 15' / ® c'I d. I ` it REFERENCES. LC Document#772644. LCC 390728 340.12 o..t, i — ----— --— _ ' 'L9y0°i i °a" FLOOD ZONE. S 84 05;39'El \ Ei Go `I , Zone C Private Co20100o a 9ht ofWa #500 03 Y July 2, I992 ------- �\— / —� may—' 0 25 50 75 100 FEET CapeSury Sheet Title: DW9 # Prepared For: C534 1 7 Parker Road Plan Showing Proposed Garage & Drive Soa1e„_ John A. & Julia A. Willis 0sterville MA 02655 1 =50 PO BOX 691 in Barnstable (Barnstable Village) Mass. Date Barnstable MA 02630 (508)420-3994(508)420-3995 rax 1 51FE8102 capesurvOcapecod.net ile � j I DATE: 6/4/99 PROPERTY ADDRESS: 221 Old Jail Lane Barnstable ------------------------ On the above date, I Inspected the septic system at the above address. This system consists of the following: 1 . 1-1000 gallon septic tank. 2 . 1-Distribution box. 3. 1-1000 gallon precast leaching pit . E`used-3o% Yly)As' pection, I certify the following conditions: 5 . _This_ is a title five septic system. ( 78 Code ) 6. 'The septic system is in proper working order at the present .time . - 7. Well water is present . If well has not been tested in the last 12 months . It should be done now. f f SIGNATURE:2 Name:_1_�_ Macomber Company: Jose2h_P. Macomber_& Son , Inc . Address: Box 66 — ------------- Centerville , Ma ._02632-0066 Phone: 508-775-3338 THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY • �� rSEPH P. MAMBER & SON, INC. �ECEjyE Tanks-Cesspools-LeachfleIds D Pumped & Installed �� JUL Town Sewer Connections —' 3 1999 P.O. Box 66 COCenterville, MA 02632-0066 T�WNpF N 775-3338 775-6412 �a y , • A E �' • e COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET, BOSTON M.A 02108 (617) 292.5500 TRUDY COX Secret.a: ARGEO PAUL CELLUCCI DAVITS B. STRU. Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION P*op.M Addr—:221 Old Jail Lane Nama of owns. Gail Renzi Barnstable address of owner: Data of Inspection: Nam. otlrt:pecta:lPl .��r 1�Joseph P. Macomber Jr. I am a DEP approved system kupector pursuant to Section 15.3-40 of True 6 (310 CMR 15.000) cornpanynwrw: Joseph P. Macomber & Son, Inc. A&LN Addrsss: Box 66, Centervi 1 1 , Ma _ 02632-0066 T d*phone Number:5 0 8-7 7 5--j-1-3 R 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 Lima of Inspection. The Inspection was performed based on my training and experience in the proper hinction ano maintenance of on-site sewage disposal systems. The system: Ppssea _ Conditionally Passes Needs Further Evaluation By the Local Approving Authority _ FailsgjA)1&6e ���'Wc •Lq/ I, / Date: V W e: t inspector's $ignansr The System Inspector all submit a copy of this Inspection report to the Approving Authority (Board of Health or DEP)within thirty (30) days o1 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 Department of�Envkonmemal Protecdon. The original should be sent coins system owner and copies sent to the buyer, If applicable, and the approving authority. NOTES AND COMMENTS revised 9/2/98 Peee 1 of 11 �� MAW on kscyct.d Paps, r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 221 Old Jail Lane, Barnstable Owner. Gail Renzi Data of Inspection:6/4/9 9 WSPECTiON SUMMARY: Check A, B, C, o/ A A. SYSTEM PASSES: have not found any information which indicates that any of the failure conditions described in 310 CMR 1.5.303 exist. Any failure criteria not evaluated are indicated below. COMMENTS: B. SYSTEM CONDITIONALLY PASSES: --Aa 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. Indicate yes,no,or not determined(Y, N, or ND). Describe basis of determination in all Instances. If "not determined", explain why not. The septic tank is metal,unless the owner or operator has provided the system Inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was installed within twenty (20)years prior to the date of the inspection; or the septic tank, whether or not metal,is cracked,structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass Inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. w Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass Inspection if(with approval of the Board of Health). broken pipe(s)are replaced obstruction is removed distribution box is levelled or replaced The system required pumphig•more thawfour-times s-yeardue to broken or obstructed pipe(s). The system wilFpess— Inspection if(with approval of the Board of Health): - broken pipe(s) are replaced obstruction Is removed revised 9/2/98 Page 2of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM WSPECTION FORM PART A CERTIFICATION (contin d) Nw-MA"—: 221 Old Jail Lane, Barnstable . 0wn.r: Gail Renzi of ld_P_ion. 6/4/99 C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: _ Conditions exist which requlrs further evaluation by-the Board of Health In order to detormfne If the system Is falling to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERJd)11ES W ACCORDANCE WfTH 310 CUR 16.303 (1)(b) THAT THE SYS IS NOT RJNCTIONwO W A wA.NHER WHfCH A1LLPRaiECT THE PUBUC UEA1THAND SAFETY"0 TH.E DTO0..40N1.tD�CT_ Cesspool or privy Is within 60 fostvt surface water Cesspool or privy Is within 60 fast of a bordering vegetated wsdand or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER, IF ANY)DETETWINES THAT THE SYSM FUNCTIONING IN A UA"ER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMEMT: The ►ystsm has a sapdc tank and soU absorption system(SAS) and the SAS Is wlth)n 100 feet of a surface wet$, si,pp+t tributary to a surface water supply. The system has a ►optic tank and soli absorption system and the SAS Is wlthln a Zone I of a public water supply wou. The system has a septic took and ►oil absorption system and the SAS Is within 60 foot of a private wet$, supply wou. The system has a septic tank and soil absorption system and the SAS Is less than 100 foot but 60 loot or more Irom a privets water supply wall,unless a well water ana)yals for collform bacteria and volatile organic compounds Ind+cstos tru wall Is free from pollution from that facility and the presence of%mmortla nitrogen and nitrate nlvogan Is aQual to 0r lao, than 6 ppm. Method used to datermino distance.- (approxlmadon not valid).• 3) OTHER revised 9/2/98 Fall 3of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (corrtinued) PropoMAdc1r"s: 221 Old Jail Lane, Barnstable owner: Gail Renzi Drte of Inspection: 6/4/9 9 D. SYSTEM FAILS: You,must Indicate either 'Yes" or 'No' to each of the following: I have determined that one or more of the following failure conditions exist es described In 310 CMR 15.303. The basis for this determination Is Identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of"Wags(rrtoiacifity-or-"stemcoritponent•duetto on overloaded orcbgged-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 a distribdqp box above outlet invert due to an overloaded or clogged SAS or cesspool. u 1� Liquid depth In r^a&o00 Is less than 6' below Invert or available volume is less than 1/2 day flow. Required pumping more tha/n'4 mos In the last year NOT due to clogged or obstructed pipe(s). Number of times pumped I6L Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a 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 I of a public well. Any portion of a cesspool or privy Is within 60 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. if the well has boon analyzed to be acceptable• attach copy of well water analysis for -coliform bacteria, volatile organic.compounds, ammonia nitrogen and nitrate nitrogen. - E. LAR GE SYSTEM FAILS: 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: The system serves,a facility with a design flow of 10,000 gpd or greater(Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes Ncd ofj the system is within 400 feet of a surface drinking water supply the system•itwithin 200 toot ofttabutery-4o a*Ulf ao"ri 4&;"9•w4tea•supP4y --- the system Is located In a niuo9on sensitive area(Interim Wellhead Protection Also -IWPA) or a mapped Zone II of a public water supply well) The owner or operator of any such system shall upgrade the system In accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further Inforittation. revised 9/2/98 Page 4ofII I ! SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST PropectYAd&"s: 221 Old Jail Lane, Barnstable Owne(: Gail Renzi Date of Inspection: 6/4/9 9 Check if the following have been done: You must Indicate either "Yes" or "No" as to each of the following: Yes No Pumping information was provided by the owner, occupant, or Board of Health. _ -Nona of the aystemcompoa,ants.baao:baan pwnped+far✓a2Jeast two.weeha and••the'aystem hasb000j*caivawg w.aaJ-low rates during that period. Large volumes of water have not been Introduced into the system recently or as part of this Inspection. _ As built plans have been obtained and examined. Note if they are not available with N/A. _ The facility or dwelling was inspected for signs of sewage back-up. j/ The system does not receive non-sanitary or Industrial waste flow. _ The site was inspected for signs of breakout. All system components,"luding the Soil Absorption System, have been located on the site. _ The septic tank manholes were uncovered, opened, and the Interior of the septic tank was inspected for condition of baffle: or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System orrthe site has been determined based on: _ Existing information. For example, Plan at B.O.H. Determined in the field(if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) 115.302(3)(b)) — The facility ownar.land.occltpaol 11 d)ffw&W from.oi4mw).warapruyided.wuh Infnrmatioa,on iha proper nainta��� �f Subsurface Disposal Systems. revised 9/2/98 Page sofII ) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 221 Old Jail Lane, Barnstable Owner. Gail Renzi Date of Inspection: 6/4/9 9 FLOW CONDITIONS RESIDENTIAL• Design flow:g.p.d./bedro Number of bedrooms(design):. , Number of bedrooms(actual):y1 Total DESIGN flow �v Number of current residents: Garbage grinder(yes or no): ( es or if yea, separatalrtspection•required Laundry(separate system) -• Laundry system Inspected ya or no) Seasonal use (yes or no): Water meter readings,if avalble (last two year's usage(gpd): �����• Ll� /C%�� ' f t;h a @ l l has n o t Sump Pump(yesorno): �,A.),�,(� e been tested in the past_ 12 months . Last date of occupancy: ! I t should be done now. COMMERCIAL/INDUSTRIAL: See pages 6 A & 6 B Type of establishment: /IV Design flow: AO,4 gvd ( Based on 15.203) Basis of design flow Grease trap present: (yes or no) "/� Industrial Waste Holding Tank present:(yes or no)AIX Non-sanitary waste discharged to the Title 5 system: (yes or no)_AQ - Water meter readings,if avail Last date of occupancy: `/� OTHER:(Describe) ZM Last date of occupancy: AIW GENERAL INFORMATION PUMPING RECORDS and source of information: System pumped as part of�insectjon:(yes or no)If yes,volume pumped: gallons Reason for pumping: TYPE OF YSTEM 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) I/A Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other AP OX.1�y�JTE A.GE�oSal_I c✓1/�. n nlddate Ansta{tn^d;t k'ow�f N�source„ot•#'Aformation: Sewoge odors detected when arriving at the site:(yes or noVf/� /� G/`v� /i��l� /✓�����`��"�b revised 9/2./98 Page 6of11 BARNSTABLE COUNTY DEPARTMENT OF HEALTH & THE ENVIRONMENT os S'J.4? P.O. BOX 427 A. SUPERIOR COURT HOUSE ' BARNSTABLE, MASSACHUSETTS 02630 • 4A55 PHONE: 362-2511 EXT. 337 SAMPLING INSTRUCTIONS FOR PRIVATE WELLS An improperly taken sample wastes your money and has neither scientific accuracy nor legal acceptance. 1. Obtain sterile sampling bottle from the County Lab or Town Health Department. Bottles sterilized at home are not acceptable. 2. It is recommended to use a straight faucet, preferably NOT swingtype. 3. Turn on the cold water and let it run for five (5) minutes. 4. Fill the bottle leaving one inch air space. Do not fill bottle to the top. Be careful not to touch the inside of the bottle or cap with the faucet, your hands, or anything else. 5. Fill out the reverse side of this form. The laboratory requires accurate and complete information. The person filling the bottle must sign the form 6. The charge for a routine well analysis (coliform bacteria, pH, conductivity, iron, nitrate, sodium and copper) is S25.00. Checks should be made payable to Barnstable County. Exact change is required if paying in cash. Additional tests require additional fees. Consult lab or a price list for exact information. 7. Samples are accepted Monday - Thursday from 8:00 AM to 4:00 PM and Friday 8:00 AM to 1:00 PM. They must be delivered to the lab within 6 hours of collection or 24 hours if refrigerated. 8. Completion of tests and results takes 7-10 business days. Results will be sent in the mail. 9. Special requests such as results in 2 -3 days and sample acceptance on Friday from 1:00 PM to 4:00 PM are available for an additional charge. Contact the laboratory for availability. NOTICE: WATER FROM THE SAME SOURCE CAN PRODUCE CONTRARY RESULTS IF TESTED AT DIFFERENT TIMES AND/OR DIFFERENT LOCATIONS THE COUNTY OF BARNSTABLE SHALL NOT BE LIABLE FOR DAMAGES RESULTING FROM THE RELIANCE ON RESULTS OF WATER TESTS ACCURATELY PERFORMED PLEASE COMPLETE REVERSE SIDE OF FORM I _ PRIVATE WELL WATER SAMPLE .DATA COLLECTION SHEET VOC VIAL NUMBERS FIELD B LA14K BOTTLE ID NUMBER DATE REC ' D NAME COLLECTION DINE MAILING ADDRESS COLLECTION TIME WELL DEPTH STREET ADDRESS YEAR WELL INSTALLED MAP/PARCEL TELEPHONE COLLECTED BY : SAMPLE APPOINT14ENT NEEDED ? REASON FOR TESTING: ( ) SUSPECT A PROBLEi-1 (EXPLAIN) ( ) REQUIRED ( ) FOR INFORMATION ONLY ( ) NEW WELL ( ) REAL ESTATE TRANSACTION ( ) OTHER (EXPLAIN) DISTANCE OF WELL FROM POSSIBLE CONTAMINATION SOURCES (IN FEET) : SEPTIC TANK\CESSPOOL FARM SALTED ROAD UST LANDFILL INDUSTRY GAS STATION OTHER TREATMENT USED: ( ) NONE ( ) WATER SOFTENER ( ) FILTER; SAI4PLE TAKEN BEFORE/AFTER TREATMENT (CIRCLE) RESULTS **** ****** ** *********** ******** **** * *** * *********** * ***** * * * * VOC ROUTINE CHLOROFORM TOTAL COLIFORM\100 ML 1, 1, 1 TRICHLOROETHANE (PPB) pli CONDUCTIVITY IRON (PPM) NITRATE-NITROGEN (PPM) SODIUTl (PPM) ` COPPER ( PP14) ANALYSIS DATE: ANALYSIS DATE : SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(corronued) ProponyAd&•u' 221 Old Jail Lane, Barnstable Gail Renzi Dsu of Inspection: 6/4/99 suiLDwG SEWER. (Locate on site plan) Depth below grade: Material of construction:_.cast Iron 40 PVC_other(explaln) Distance hom rivate water suppl well r suction line 1 S Diameter r/ Comments:(condition of Joints,venting, evidence of leakage,-etc.) J 0 i S C ANK• Se vent . (locate on site plan) l� Depth below grade: Msterlal of construction: concrat9,sj� stat V fiberglass.CAPolyethyleno�ther(explaln) IV It tank Is Instal,list age Iff Js.age.conrtrmed by Certificate of Compllanc (Yes/No) Dimensions: Sludge depth: Distance from top o_jkludgo to bonom of outlet tso vrtraHle. Scum thickness: S(—� / Distance from top of&cum to top of outlet tea or bafflo: Distancs from bottom of JA scum to bo 0 of c outlet tee baffle: How dimensions wets detarmined: IWIW Comments: (recommendation for pumpin,y .condition oLlnlet and outlet tee& or-baffles, depth of liquid level In relation to outlet invert, avucturnl:nte,rity evidence of leakage, etc,) Yiitnp tank every 2-3 yaare Inlet & Gutle-tz tees in. place . Liquid d rr , struc e , GREASE TRAP: (locate on site plan)Depth below grade:VA Material of construction oncretoq�motafiberglass/J�QPolyethylene�,*ther(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet too or baffle: 414 Distance from bonom of jLcum to bottom of outlet too or baffle: 44 Data of last pumping: Comments: (recommendation for pumping, condition of Inlet and outlet teas or baffles, depth of liquid level In relation to outlet invert, structural intogrit) evidence of leakage, etc.) Grease revised 9/2/98 PaEe7ofIt SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) P*opeMAddrou: 221 Old Jail Lane, Barnstable Own": Gail Renzi Dav of Inspection: 6/4/9 9 TIGHT OR HOLDING TANK(Tank must be pumped prior to, or at time of, Inspection) (locate on site plan) Depth below grade: R3 Material of cons tructionA�fconcrateAt4metal�AFiberglass(&olysthylene,&other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm present Alarm level:Alarm In working order:Yes N-1AW Date of previous pumping: , -4 Comments: (condition of inlet tee, condition of alarm and float switches, etc.) Tight or hOiding tanks are not nrPGPnt _ DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet Invert: Comments: (note-if level and distribution is equal, evidenoe of solids carryover, evidence of leakage into or out of box, etc.) — - Distribution hnx hac two lato,-ale . Ne evidenee—of solids Cully No avirjanrA of 168kage ante er-9te_ r the box . PUMP CHAMBER:A�Vel (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.) umD chamber i -, not raaent j revised 9/2/98 Page 8ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (corrdnued) PropeMAddreas: 221 Old Jail Lane, Barnstable Owrw: Gail Renzi Date of Irupecoon: 6/4/9 9 SOIL ABSORPTION SYSTEM(SAS)L (locate on site plan,If possible:excavation not required,location may be approximated by non-intruslve methods) If not located, explain: Type: leaching pits, number: leaching chambers, number: � ,� v� leaching galleries,number: � _ leaching wenches, number, length: � leaching fields, number, dime slops: overflow cesspool,numb '.y Alternative system: j� Name of Technology• Comments: (note condition of soil, signs of hydraulic failure,level of ponding, damp soil, condition of vegetation, etc.) Loamy sand to medium fine Band NO 918ne of Lydsaulie fai III ra nr nnnrl a e i nn r( C' ,; l T,Parhl ng =i t t' r ^Y� � _ e�-the—p rr e e}e r CESSPOOLS: , (locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensiohs of cesspool: Materials of construction: Indication of groundwater: inflow(cesspool must be pumped as part of Inspection) 0 C RA=on1 g nra nnt,—PS®s® 1= e Comments: (note condition of soil, signs of hydraulic failure,level of ponding,condition of,vagetation, etc.). Cesspools are not p-PCPnt PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, revel of ponding, condition of vegetation;etc.) Privy is not present - revised 9/2/95 . Page 9of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM WSPECTION FORM PART C SYSTEM INFORMATION (corrdrx ) Peop*MAd4re44: 221 O1d; Jail Lane, Barnstable Own.': Gail Renzi °a" ct 4"°"aa" 6/4/9 9 SKETCH OF SEWAGE DISPOSAL SYSTEM: Include tlas to atleast two permanent telstence landmarks or benchmarks locate all walls wlWn 100' (locate white public Water supply comas Into house) Rf�r^ revised 9/2/96 Page 10 of 11 MRY-27-1999 13:07 COTTON REAL ESTATE_ pyy ;p 76'e' 4p'h ,%ply '� f'�l ,'.� iv,°�fr li,•rl',�v 1�'I' `ik;ih'n,!", j r•- e•e PI er a ID Q ® G i m I I Y •••r �.+� aaaa ' 4 •• w•w .1•IoM ti Subject » .. ' I p(reedoas: 6A West of Barnstable Village to()Id Jail Lane to#221. ' See more color phMs of this property online ac w cv.cottonre.Com TOTAL P.03 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 221 Old Jail Lane, Barnstable °"n": Gail Renzi Date of Inspection: 6/4/9 9 NRCS Report name Soil Type_ Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep _ SITE EXAM Slope Surface water Check Cellar Shallow wells rr�� Estimated Depth to Groundwateo[O Feet Please Indicateall the methods used to determine High Groundwater Elevation: .✓ Obtained from Design Plans on record /Observed.Site(Abutting hole, basement sump etc.) property, bservation ✓ Determined from local conditions Checked with local Board of health Ch ked FEMA Maps Checked pumping records _ZChecked local excavators, installers Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) Used water Contours Map . Gahrety & Miller Model i� i revised 9/2/98 Page 11of11 ta•�nr. -n.r�+Tr.rn�mr•n�n.-r.n aw�.�+.nn�.+Rrn�.+nn nr'wv��n w'n .rt.-r-.-.--.v'n.-•'.....r-... I '1'UNN OF —RARNSTABI R WARD OF HEALTH ,SUBSURFACF, SEWAGE p131'USAL SYSTEM INSPECTION FORM - PART D •- CERTIFICATION J �_ �-••►nor••.-: .-�.:n�.*rnmrw•n.rr,rN+r�rw�m•r.'-a'f.-,vrnry wwsr"Trr�r nrs rrm nrmr�n•�arrra+.rr..•..•r �..A T•.+•fir -TYPE OR PRINT CI-EARLY- PROPERTY INSPECTED STREET ADDRESS 221 Old Jail Lane Barnstable ' ASSESSORS MAP, BLOCK AND PARCEL # OWNER' s NAME Gail Renzi PART D - CERTIFICATION NAME OF INSPECTOR Joseph P. Macomber Jr . COMPANY NAME Joseph P. Macomber & Son , Inc . COMPANY ADDRESSBox 66 . Centerville Ma . 02632-0066 Strout Town or city Stat. t1P COMPANY TELEPHONE ( 508 ) 775 - 3338 FAX (508 ) 790 -1578 R CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this nddress and that the information reported is true , accurate , and complete as of the time of -inspection . The inspection was performed and any recommendations regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems . Chec one : Sys teui PASSED The inspection which I have conducted has not found any information which indicates that the system fails to adequately protect public heR1L11 or the environment as defined in 310 CMR 15 , 303 . Any failure criteria not evaluated are ns stated in the FAILURE CRITERIA section of this form, System FAILED* e The inspection w}licll I have con'�Dcted has found that the system fails to protect the public health and the environment in accordance with Title 5 , 310 CMR 15 - 303 , and as specifically noted on PART C - FAILURE CRITERIA of this Inspection form . Inspector Signature Date One copy of this certification must be provided to the OWNER, the BUYER ( where applicable ) and the IlOARD or .HEALTH. • If the inspection FAILED, th'e owner or"oporator shall u within o'ne ,year of the date oP the inspection , unless alloweddortrequired otherwise as provided in 3.10 Ch1R partd . doc r _✓No.... � � �'7S�06� J Fas. .0 �� .... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF •BARNSTABLE Appliratinn for Dinpnoul 3fnrkn Toni#rur#inn Prrntit Application is hereby made for a Permit to Construct ( ) or Repair (y) an Individual Sewage Disposal System at: ............... ................................... ............................. Location- ddress �� or Lot No. • .... ........ .�/� ... s. 4 x---•---..... �-T:.L?p 1 � '� .�... ��............... ...... __.. Uwn r �] ................ Address-- ................•-• !- � - �-� � _y ►� Installer Address Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms...V....................................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of persons............................ Showers ( ) — Cafeteria ( ) WOther fixtures .••••••••-••;........................................................................... W Design Flow........ ........................gallons per person per day. Total daily flow....t?.�.........................gallons. C4 Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No. .................... Width.................... Total Length......................Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft Z Other Distribution box ( ) Dosing tank ( ) `-t Percolation Test Results Performed by.......................................................................... Date................................. Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water............-........... (i, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water...--.-......- .............. ----------- ------- -----------------..... -...................... -.......... •................................................................................. 0 Description of Soil••••••••••-•....••••...---•-••••••••-.....-••....................•--•••.....•••------------....-..._.....--......._._................................................... U .......................=................................................................................................................................................................................. W ----•------------ ----•------------•---------•---------..-.......-------....---.....--•--------....------.--...------------------------....----.._......-••-•-• .----................................U Nature of Repairs or Alterations—Answer when applicable.....�4-0....C.tip.... 1p E-......5 Agreement: The undersigned agrees to install the aforedescribed Tndividual Sewage Disposal System in accordance with the provisions of'I Ili 5 of the State Sanitary Code— The tiro rsigned further rees not to place the system in operation until a Certificate of Compliance has ' ed b D-aru o 1 . �/� (y_ Signed............. . ... .. .... . _..�- ..........•-••_-•••- y Date Application Approved By-•_._...... - •......... ................. .. ...... ....................Date -.--.-.............. Application Disapproved for the following reasons:..... .....................................................................................................te . F r'� �isa ...._......- Permit No... - ........... Issued..... ... ,,,,7........._.... ` Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE , Appliration for Bi�posul Works Tomitrurtion Permit Application is hereby made for a Permit to Construct ( ) or Repair (,,C) an Individual Sewage Disposal system at: ................ _ :.�.._ ol.(�.3 _�-tr:P.....---....... ....................................... :............... - -••---.------ .... Location Address or Lot No. ................... _- .---....----............ ......� Address ........ �....1?r n,6 c.• l:z�^ �___ .. � Uw er •--._..._.. ...................... a } r� L- (✓ c�-t �1 ( r� .................. �!........ ✓.... - . IA:.:..............1.......... _................._ 7f�_ �....��..� ....•• . Installer Address Type of Building �/ Size Lot............................Sq. feet U Dwelling—No. of Bedrooms..7..:...................................Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ............ No. of persons............................ Showers — Cafeteria aOther fixtures ........................•-•----...... ............................................................................................................... W Design Flow......... .......................gallons per person per day. Total daily flow....` �6 .........................gallons. 04 Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ . x Disposal Trench—No. ............ ...... Width.................... Total Length_................... Total leachingarea....................s ft. 3 Seepage Pit No..................... Diameter..................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water...................:.... (To Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ P4 .................................. •....... --.-......---------................... ................... ......•-----•--.................... ........ 0 Description of Soil........----••....................................................................•------•........_............-----•--••-----•--....---••---- ••-•-.................••- W ......-•-••-•...--••••--•---••-•.............................••---•....------•------•-..........-••••.........---•----------.._.............•-••--...-••••--••---......_.........._...................... W ••.............................••-••••-•---•-•••-••--•••••••-••-...••••••••------•-••••-•................••-•........_....••••••---•---•••••---•-•••-------•-••......--••••......--•................... UNature of Repairs or Alterations—Answer when applicable..__. 0-e......_. .......... .. Agreement: The undersigned agrees to install the aforedescribed Tndividual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code— The undersigned further grees not to place the system in operation until a Certificate of Compliance has been issued by oar tl Signed .. '/J .�t � •..... . •---C. :.............. ... .7132.--.- I ..............Date.............. Application Approved BY......i....---�� ��C� .....�. _:....��:l�l/�i`�l�/�/� ......v r ` Date Application Disapproved for the following reasons:.-•-••• ...............•-....-------••-•--•----...............---•----......................._.....--..---- ................................... ................ ..` �..... _.................................................................. .. ......... ..,•'.Date.............. -�! Permit No.... >� ....... L. �`� �ae ,�`-2...............t.... ...... Issued... �. � 7 THE COMMONWEALTH OF MASSACHUSETTS BOARD' OF HEALTH TOWN of BARNSTABLE Trrtifiratr of TOMpliaM THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (�c) by....................•---•-••-•-•.....---.__ `!•I^-• ?'..�:v!:. ..� ?? .................. ......... .-............... .-....... ....... ............. ....... Installer at....................................... ,......O..I.K.- ........- ........... has been installed in accordance with the provisions of TIjj7,�E 5 of he State Sanitary Code,as described in the application for Disposal Works Construction Permit N-__4_... - .. _.�.� dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONS UED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. ............... p -----•---•.....- A- .............DATE..........`�....... .. . _........... Ins ecto ..THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN of BARNSTABLE No.. .... ... FEE... ",....... Disposal Works Tonotrurtion Permit Permission is hereby granted........................... =, ^:•:-=ZZC•`- -.. to Construct ( ) or Repair (�c) an Individual Sewage Disposal System ' atNo............................•...... •� �.1......../�i 7 ,t �i .--.s=_�:.-G' Street 4 i as shown on the a licatio for Disposal Works Construction Per7,7/ ' � ... r.�r.. . ........ .. .................. �-•••• Boanl of Ifealth DATE............ C/ �....................•---...... I �• Y ,r I _I I G I 1 V i — l � I I — c Z a 1 a tir I i I f v lol f� I x � I 7vg ou. S^tee (^'� 9x R crr IIcc.2 !� '9';c d'•,v ,xo•E I� .. 9'x 3"7Rnujv,:. C ix 8":'?,1NrvGl O 9'>.?"ri'�a•.:r�,9 C' ----! I lot x I � L i O 1 I , 1^ 4 9 114 r a r� �I --- - _ ir K vo q� 1 TOWN OF BARNSTABLE LOCATION L �T ( d jS SEWAGE # Z_�f VILLAGE ASSESSOR'S MAP LOT INSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITY b p LEACHING FACILITYAtype) 1 (size) o NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER n 7 _ DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No m 0 u r`I y � t j.1 No ._.._..-... Fxs .... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH oy ?x .......-.....1 ........ .---....OF.-...... ..........^.!•• c�'JIB.................................... �`✓ Appliration for Disposal Works Tonstrurtion Frrmit Application is hereby made for a Permit to Construct ( <) or Repair ( ) an Individual Sewage Disposal System at: ----- Location_Address - -- -- •-. --- or Lot No. --........_. �5�---............. ................................... .....................•----...._..........._ .---..................... .... .....-- - .. w ` Address a ..-•-•••--••••---•---••...---•--_._.P... ..../V.. ...................... ..............................•--.....-------.............--------.._..--.--------•--............. Installer Address Type of Building Size Lot_. 7. ---Sq. feet aDwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) a Other—Type of Building ............................ No. of persons.......,............... ....... Showers ( ) — Cafeteria ( ) Pa Other fixtures ..................... -------- --------•• ••- d Design Flow..........:.. 5.` . .....................gallons per person per day: Total daily flow..:_...�3` __.._...._............gallons. Septic Tank Liquid ca.pacity_� gallons Length__�`� y Width:_�1 .`_ Diameter.....:.......... Depth... .t..S?K Disposal Trench No:.................... Width..................... Total Length.................... Total leaching area...................sq. ft. 3 Seepage Pit No........1.......... Diameter.....k!;;?._...... Depth below inlet....... Total leaching areasf Z Other.Distribution box (, Dosing tank ( )� Percolation Test Results Performed by...__ Le ................................... -12:.8 _____•___.___. ,al Test Pit No. l _G.1' minutes per inch Depth of Test Pit.... `f:`f .._.. Depth to ground water.... 1.Cy\A___... 1.4 0_ Test Pit No. 2__�Z._minutes per,inch Depth of Test Pit..... 32 K.... Depth to.ground water.....!Ngf:� a .. Description of Soil---...:-••--••- 1rJ�C?`=^------------ .................................... S 11PEBITIIV . .::.......... = 1Gt�INQ. Gtf1EE ul.FAIR........ W _•• - - -- ----- -:. SIIkLLAT10N AN®"� Tss�-_ u.STRIC..---......_ -- --• _ - U Nature of Repairs or Alterations-Answer when applicable -4E_:SY.TEM WAS �- PLAN:-------------.....•-.......... ------••-------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITI1 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issged oarg ff ealth. Date ApplicationApproved By•••••-•••••-....••-••-•-•- --•--•-••-•- .........•-••••••-••••---•-•••-- ........................................ Date Application Disapproved for the following reasons:...........................................................................................:................. ..............•-------..........----•--•---•---------.._....-------..._.:.-•----•--..._._....-------.-._..--•-=-•--------......_....--------:....---......._...--•-•---•------..._........••-••••--•--. ate PermitNo...............�-- 1_. _...... Issued................................................D -- ate THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...........d.o. ............OF....... V.--'......................................... Trrtif irate of Toutplinurr THIS ISM TO kERT FY, Tha the f ndividual Sewage Disposal System constructed ( ) or Repaired ( ) by-••--•---•-_---------•••-••-_- _......rn`� t 1�...........................•------•------•--.......-----•--.........----•------.__-_-_-•----------•--•-----____-_-__-________ Installer S at :_..L.... --•------v...� Cr= `-•---••----(--Cie•--� ram- - has been installed in accordance with the provisions of TITLE, 5 of The State Sanitary Code as descriped t' the application for Disposal Works Construction Permit No....... __''�L`7. dated__--._____-�_f_._�_�.J_..... ....... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE-••----•---••...................•--•-•-----•---•---------•--•--•--•-........... Inspector..................................................................................... `F�"'i'.�-frfi'3,J'i.0 r::..._Yiv.'.. ,� •i,. ,f �. ., :.1,�..t..�.,.....,ra-t.•,.��^.:wr-^-...i�^.e+<'.w».a.. ry....r+.+N�►i+w�ti!`i:�T' � �'`"`yti°f.� M"f;' -�� ,�tt. .r�.-i�J..�r�^�`i:•d.-'�rs..ei'4a,Sl%"w.,..J-...r•,Ki .,y,.�w wma.w' ,3«.. �,.r w;.,....:-.'Y.se.t=,„+; +�s. sv�c-�., THE COMMONWEALTH OF MASSACHUSETTS r BOARD OF HEALTH .............�. /1........OF.........1... ............................: ::..................................... Appl ratiaan far' Disposal Marks Tonstrurtion ra mit r. Application is hereby made for a Permit to Construct ( +Q or Repair. ( ) an Individual Sewage Disposal Yam. C7 C Location-Address or Lot No. •............. tY1;C..:= ..._..._.._..._.... ----•--•-•••-•--.._..---...... ....---......... --•-•----................ ..... .... ----- �� Owner f �� Address `! .................................. ......r.------•-•-------------------....... ----...........-----•-------•----.............. Installer Address Type of Building Size Lot.-F�--' 21_: (2...Sq. feet Dwelling—No. of Bedrooms.............3.............................Expansion Attic ( ) Garbage Grinder ( ) `-� Other—Type e of Building No. of persons........... ............... Showers — Cafeteria G4 YP g --------••••---•-••-••_....- P ( ) ( ) a' Other fixtures .........!................................... WW Design Flow.............:_.`.�................;.....gallons per person per day. Total daily flow..:_.. �?��_.....................gallons. W Septic Tank=Liquid ca acit .!9: lons Len h..� _'_ Width.. :::.�.. P q P Y g� gt Diameter................ Depth_.LP r--) x Disposal Trench—No.....................tWidth.................... Total Length.................... Total leaching area...................sq. ft. 3 Seepage Pit No--------t........... Diameter..... ©`...... Depth below inlet...... ......... Total leaching area. I .=sq:-ft_41'►/_) Z Other Distribution box O Dosing tank z- Percolation Test Results Performed by.... icT.r ;l Date ......-•.............. ... Test Pit No. L_G.........minutes per inch Depth of Test Pit... y ..... Depth-to!ground water...or.—Q...._.. Test Pit No. 2.. z_..minutes per inch Depth of Test Pit.....3:? ...... Depth to ground water.....k sA ..... -. .� `0��'� _ O Description of Soil...............� f .......................---.............................................................:.:...•...... ..••-•-'...----•----•-•---•-•.._........_..--••-•---..._.....----•---•....._...................... U Nature of Repairs or Alterations—Answer. when applicable...........................:................................................................... •--•----•--------------•----'--•-------•----•-----....................................................................----------...........-----...------........-•-•-•-•---------•---•-................ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by) the oarpd,-fliealth. _Signed........................../ ------..'lr=G:......................•-••-----• --'-...................I.... . ��. I Date A lication A roved B ............::..... . - - :_ Date Application Disapproved for the following reasons:........................................................................................................... � f ....................................................................................................................................................................................................... Date PermitNo Cam: - .1... .._.._ Issued-....................................................... ate --.--- ---- ——————————---——— ----------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH - ...........J.® .r.!> ............OF........ .....................A................................................. =--- (In if ratr of Taautplitt"It THIS 1S TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) ,or Repaired ( ) b — ..'I....... 'bG ti t Y-.. ......---•--. ....- ...__.. .- ..... ............. ._..._..- ............................_.......... Installer ?=at............ - A....-a------------ ------•---pnc�—_-- .f. c"a---.........................................................- has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as describedcin the application for Disposal Works Construction Permit No.....—;!S, '_."��1 `�. dated...........( _�..). THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE..............................•---............------•----------------........... Inspector.........................................................._......................... ._..._,-------_-------------------------------------- W ) jam �( . THE COMMONWEALTH OF MASSACHUSETTS -- --------1---L� Njoipmi �, _ — ;-- BOARD OF HEALTH No � F> ...............�. aJ..............OF.. ` N: ..... a>L. �... . Disposal-18orks Taanstrttrtiaatt Prrutit Permission is hereby granted... t -----.M. f-Q...................................................................................._.._. to Construct ( ) or Repair (`) an Individual Sewage Disposal Syystem at No.-.......L .......--..:a.............C. .................. e Q,.---•--.....1n N--------•------.------•---•------................... .................... Street <2 P Construction :-:�.��1 D'ated.._....--c----------------�........ as shown on the application for Dis oral Works Construe to/ Board'of Health " DATE..... r ---------r ................................. Department of Envirbnmental Management/Division of Water Resources WATER WELL COMPLETION REPORT WELL LOCATION Address �. ^'1 a / t C City/Town r•, G.S.Quadrangle Map I Grid Location Owner._I. t 4r i C i ^ fri i tl Address PC% L^c y' . Lt X. i r WELL USE CONSOLIDATED WELL Domestic❑"Public ❑ Industrial ❑ Type of Water-bearing Rock Other Water-bearing Zones i r Method Drilled 1) From To 2) From To Date Drilled ;r_• �'� 3) From To 4) From To CASING Depth to Bedrock Length r�/a Diameter Type UNCONSOLIDATED WELL STATIC WATER LEVEL' Water-bearing Materials Feet below land surface �''`/ Sand: fine❑ medium❑ coarse0 Date measured rr' 7 Gravel: fine❑ medium❑ coarse[-] Screen: GRAVEL PACK WELL Slot# 16 length from 97 to/,^-0 Yes ❑ No Q Split Screen (or 2nd screen) WATER QUALITY TESTS MADE Slot# length from to Chemical ❑ Biological 0 Depth To Bedrock PUMP TEST Drawdown feet after pumping days hours at GPM. How measured Recovery feet after hours. LOG of FORMATIONS COMMENTS: (On well or water) Materials From To Cb �- ✓ / / W .14.KI ,,�c CtrorM Drilling Firm !^ Address yaruwuthp AfA GQ664 \ Cit Registration No. ��� 4,, Operator's ignature Please print tirmly BOARD OF, HEALTH COPY -f, ,J ' isM-z sak7sa7i s s j Log Number: "Bottle # E882 'Date: 7-81-87 BARNSTABLE COUNTY HEALTH AND ENVIRONMENTAL DEPARTMENT SUPERIOR COURT HOUSE V BARNSTABLE, MASSACHUSETTS 02630 o • AS$ DRINKING WATER LABORATORY ANALYSIS PHONE: 362-2511 Ext. 337 Client: Dave Dovell Collector: R. Clifford Mailing Address: p_n_ Rox 676 Affiliation: well driller W Dennis, MA 0 670 Time & Date of 7-28-87 Collection: 4,o o n_m Telephone: Type of Supply: WP11 Sample Location: Well Depth: 1001 Date of Analysis: 7-29-87 11 •00 PARAMETER SAMPLE RESULT RECOMMENDED LIMITS Total Coliform Bacteria/100 ml 0 0 H 5.7 Conductivity (micromhos/cm) 92 500.0 Iron ( m) .1 0.3 Nit-rate-Nitrogen ( m) .6 10.0 Sodium ( m) 10 20.0 I . X Water sample meets •the recommended limits for drinking of all above tested parameter: II . Based only on results of the parameters tested for this sample, the water is suitable for drinking but may present the problems checked below: A. Water sample has higher than average levels of Nitrate. Future monitoring is recommended (2-3 times per year) to establish any upward trends. B. The low pH of the water may shorten the useful life of the house's plumbing'. C. Water may present aesthetic problems (taste, odor, staining) due to D. Water sample has high levels of sodium. Persons on low sodium diets should consult their doctor. III. Due to one or more of the reasons checked below, this water sample is unfit for human consumption: A. High Bacteria B. High Nitrates fhe Barnstable County Health and Environmental REMARKS: e , lterpretations or conclusions made by anyone Ise concerning these results without written consent. CC: Barnstable Board of Health CC: Clifford Well Drillers 1 /7/85 Laboratory Director V' Explanation of Test Results Total Coli form Bacteria Coliform bacteria are an indicator of the sanitary quality of a water supply. Water supplies may become con tam inated,from malfunctioning septic systems, cesspools and surface runoff. A total coliform count of zero indicates that your water supply is safe and approved for human consumption. A total coliform count of greater than zero is most often the result of accidental contamina tion of the sample bottle through im ro er sampling ng methods. For this reason, it would be advisable to retest any well water that is not approved. PH pH is the measure of acidity oralkalinityof the water.On the pH scale,the number 7 is neutral, less than 7 is acidic and more than 7 is alkaline. The pH of water on Cape Cod tends to be acidic in the range of 5.0 to 6.5. Conductivity Conductivity is a measure of the dissolved salts in solution. Amounts in excess of 500 micromhos/cm are generally Y considered unacceptable and may have a laxative effect upon users. Iron The presence of iron in water in concentration of .3 ppm or greater may: give the water a bittersweet astringent ' taste, cause an unpleasant odor, often gives the water a brownish color and cause staining of laundry and porcelain. The average concentration of iron in Cape Cod's water is .2 - .6 ppm. Although the presence of iron in water may cause the problems listed above, it is not considered deleterious to health. Iron may be removed by use of an iron removal system.. I Nitrate-nitrogen The Massachusetts Drinking Water Regulations have set a maximum contaminant level for nitrates at 10 ppm. Excessive concentrations may cause methemoglobinemia (an infant disease) and have been ,suggested to form potentially carcinogenic nitrosamines. Contamination sources include fertilizers, cesspools and industrial wastes. Copper Due to the acidic nature of the water on Cape Cod, copper tends to leach from pipes.-This normally does not present a health hazard; however, concentrations in excess of 1.0 ppm may cause a metallic taste and/or a bluish-green stain on porcelain fixtures. Sodium A concentration of sodium over 20 ppm is only of concern to people who are on a low sodium diet. If the water supple has than 2Q m.sodiumjt.is u to the people who are on such a diet to find n,., .,,PP: , P P P another source of drinking eater or contact their doctor to determine if consuming the water is advisable. Concentrations exceeding 50 ppm indicate that ihere may be ocean water or road salt runoff water getting into the well. g 'M t �t t ' 94+ a I dr 0 m , 236 t\ exisr. LE•4U� tn1-r I.` FQ U 4 OAT I o W Q r � J I \ \ N V6V.�L,L �W 39 J. Q - V . .3 PREPARED FOR DAVE DOVELL CER T/F/ED PLO T PL AN LOCATION: BARNSTAB LE, MASS. SCALE.• 1 4-y DATE- SEPT. 25, 1981 ocq,,�,TFo REFERENCE L OT P.B. _p L.C.P. 390-12 B FLOOD ZONE C" ' �P�ZH begs �y,� �E �E, I HEREBY CERTIFY THAT THE BUILDING r L0,, '(>>R 807 SHOWN ON THIS PL AN IS LOCATED ON THE n f GROUND AS SHOWN HEREON AND THAT IT IGIST ,j> 4 CA5 CONFORM TO THE ZONINGLIF;�J';,+ BY-L Ad d'S OF THE TOWN OF [3�1Z t.1 ;5�f A$ L!P r►r � a WHEN ON S TRUC TED. ' JDATE 1 Z ,j 4 V O 1p f�l � N W Z SPAT U 4 .- FQ 0AT10N Q f � J 8 g1+ J N `l 108 • Q J 1: 46.84 N A V 3 PREPARED FOR DAVE DOVELL CER T/F/ED PLOT PL AN LOCATION: BARN5TABLE, MASS. SCALE.• 1 40 DATE- SEPT. 25, 1981 2-ATEo REFERENCE L OT. 1 P.B. P. L.C.P. 390-7z 5 FLOOD ZONE C- �P`jH hrgs �c> RQU I HEREBY CERTIFY THAT THE BUILDING SHOWN ON THIS PL AN IS L OCATED ON THE 807 GROUND AS SHOWN HEREON AND THAT IT GIST'� %,� CONFORM TO THE ZONING ` �u��', B,V-LAWS OF THE TOWN OF 5ARu 57a'6 LE' ➢�►.,�.p4 WHEN �::G►i1�STRUCTEO. I .__ _fJ_.1:_• [._ (ice /1 G:.• `' TOWN OF/B,ARNSTABLE �� Q 1,0 :ATION ' 0tOl ]A//r �L�✓� SEWAGE # VILLAGE V -/c ASSESSOR'S MAP &.LOT -7 5�6 INSTALLER'S NAME&PHONE NO. O SEPTIC TANK CAPA(rl'Y " LEACHING FACII.rrY: (type) / �� (size) 3 9 >� -22C�z NO.OF BEDROOMS BUILDER OR OWNER J 4 . ®��►'/ / y PERMITDATE: Otj�COMPLIANCE DATE: Separation Distance Between the:. Maximum_Adj4sted Groundwater Table and Bottom of Leaching Facility . __ Feet Private Water Supply:Well and Leaching Facility (If any wUlls exist ��d on site or within 200.feet of leaching facility) Feet Edge of Wetland and Leaching Facility( an Facili. If wetlands exist Y within 300 feet of leaching facility) Feet Furnished by -- 71 J I ' Ile - i r7t3�t't 4 Jj 1 _ 1 I Rs- P (1" r' Fes, _i+r.- : Sn z lad'9`yl� � -'try}• . i s 1 �s Si � 1�I It s 3.�J�cyx9 qt►� I 1 l4 J— - s I ' / IN st tS , i + I I ?' g.. _.... ate.._.._-_.......,_..._.,._. _ 1 Z�Iou' SYSTEM PROFILE TEST HOLE LOGS I ACCESS COVER TO WITHIN 6" OF FIN. GRADE (NOT TO SCALE) PROVIDE INSPECTION PORT WITHIN LISA LYONS, RS ACCESS COVER (WATERTIGHT) TO 6" OF FINISH GRADE ENGINEER: g TO 79.0' MINIMUM .75' OF COVER OVER PRECAST / I WITHIN 6" OF FIN. GRADE 2% SLOPE REQUIRED OVER SYSTEM DAVID STANTON, RS ' 7/.0 WITNESS: 2" DOUBLE WASHED PEASTONE .I DATE: 1/15/04 I ' RUN PIPE LEVEL FOR FIRST 2' 3' MAX. PERC. RATE _ 3 MIN/INCH PROPOSED 100053 ** ** GALLON SEPTIC 74.80' H-20 74.33 CLASS I SOILS P# 75'05 TANK H- 10 10a'S ( ) BAF LE 73.92' �� 73.75 73.5' O O C] 0 O L� 0 0 l� 0 0 a 1:1 =1 1`7 IO ED O 'T71 ''M ELEV. �6" CRUSHED STONE OR MECHANICAL 2' 0 177 71.5' 79 0' MIN COMPACTION. (15.221 [2]) SLOPE) MIN 4' MIN ( 1 y SLOPE) 3/4" TO 1 1/2" DOUBLE WASHED STONE 0 UNSUIT. DEPTH OF FLOW ( 7. SLOPE) 500 GAL. H-20 LEACHING CHAMBER 6 TEE SIZES: " i INLET DEPTH = 10 g LOCATION MAP NTS OUTLET DEPTH = LS 14" LEACHING ! j UNSUIT. ASSESSORS MAP 278 PARCEL 50 CO FOUNDATION 42' SEPTIC TANK 59' D' BOX 5# FACILITY S // **CONTRACTOR TO CONFIRM FEASIBILITY OF PROPOSED 5' 25" 10YR 5/6 INVERT ELEVATIONS PRIOR TO INSTALLATION OF ANY PORTION OF SEPTIC SYSTEM C1 DISTRICT WATER PARCELS 2-5 AND 2-6 LS/SL UNSUIT. + 76.6 + 75.6 I 66.5' 2.5Y 6/4 BENCH MARK - CORNER OF - 76" 72.6 CONC. APRON ELEV. = 78.6 342.76' .4 -► -� `� � 76.1 C2 �A �� �6 'Ill- '4 + 74. PERC 6)+ `°P.3 :+ 77.8 PIARCIEL CT 49AT5R F$ LOT 1 6 77.2 7. 76. 75 L=44.72' 2.5Y 6/3 89,271 t SO. FT. s + 65.3 R=26.94' sj 6+ 150 5' REMOVAL OF UNSUITABLE SOIL REQUIRED " 66.5' �•. AROUND PERIMETER OF LEACHING FACILITY, 6 6 \ 660 \) DOWN TO SUITABLE SOIL LAYER (TO C2 LAYER ENCOUNTERED I + 77. EXIST. - SEE TEST HOLE LOG). REPLACE WITH CLEAN NO WATERE (��'� S: 6p GARAGE ' + 7 3 MED. SAND. ENGINEER TO IN AND > 2 3 Z (SLAB) , CERTIFY REMOVAL / APPROX. NGVD a iv 1. DATUM IS I'156 W 78.6 pN- 76.8 SEPTIC' DESIGN: (GARBAGE DISPOSER IS NOT ALLOWED ) 77 + 4 ��'i + 78 0 2, Uk InurlPAk. WATER DOES NOT EXIST j r; DESIGN FLOW: �_ BEDROOMS ,( 110 GPD) = 220 GPD 3, MINIMUM PIPE PITCH TO BE 1/8" PER FOOT. 8 P BO D RED t788. .6 220 DESIGN FLOW P G LO _ RIVE USE A GPD DES 10 GRAVELH H e � 77.00 4. DESIGN LOADING FOR SEPTIC TANK TO BE AAS 0 e8e �\ �9 - ',' ^ 77.o SEPTIC TANK: 220 GPD (2 = 440 FOR LEACHING CHAMBER & D'BOX, H-20. 8, 8 8 .7 - -+- - -1�7\ F rn USE A 1000 GALLON SEPTIC TANK 5. PIPE JOINTS TO BE MADE WATERTIGHT, 0 8 55 T 7 •8 1_, LEACHING: 6 ENVIRONMENTALCONSTRUCTIOND CODE ST TITLE BE IN IN ACCORDANCE WITH MASS. EXIST. _ DWELL. 0 8786 6.3 SEOP. 15 IC N GAL 77.2 >`a, SIDES: 2(16.5+ 12.83) 2 (.74) - 86 . 7. THIS PLAN IS FOR PROPOSED SEPTIC SYSTEM ONLY AND IS NOT 88 s . W nr 16.5 x 12.83 (.74) = 156 TO BE USED FOR ANY OTHER PURPOSE. 8 s 7 BOTTOM: 8. PIPE FOR SEPTIC SYSTEM TO SCH. 40-4" PVC. PAVED + 85. .6 TOTAL: 328 S.F. 242 GPD 9. COMPONENTS NOT TO BE BACKFILLED OR CONCEALED WITHOUT DRIVE + 2.6 USE (1) 500 GAL. H-20'"LEACHING -CHAMFER` WITH 4' STONE INSPECTION .BY BOARD OF HEALTH AND PERMISSION OBTAINED ALL AROUND FROM BOARD OF HEALTH. OD + 90.13 90.% A *(FOR EXIST. GARAGE ONLY, CONTAINING SINK AND TOILET) HOUSE IS ON ITS OWN SYSTEM TITLE 5 SITE PLAN 1yo o�7�. W � m � 80.9 LEGEND 77.9 100.0 PROPOSED SPOT ELEVATION OF � o.� '� 221 OLD JAIL LANE 100x0 EXISTING SPOT ELEVATION - I IX,ST. ,,,IELL ? IN THE TOWN OF: ,00 PROPOSED CONTOUR BARNSTABLE (VILLAGE) 100 EXISTING CONTOUR ' PREPARED FOR: B0RTOLOTTI CONSTRUCTION/WILLIS 78.3 DISTRICT WATERY 30 0 30 60 90 PARCEL 49-3 L=46.84' BOARD OF HEALTH JANUARY 19, 2004 340.12' R=29.51' MA 1 = 30' APPROVED DATE SCALE: DATE: REV. 2/19/04 (ST) REV. 2/24/04 (MOVE SAS) off 508-362-4541 fox 508 362-9880 OFH ofso ' down Cope engineering, Inc. °�� ARNE H cy\ �� AR E yG�, OJALA '^ CIVIL N 0 OJALA y CIVIL ENGINEERS No. 3.0792 .6 6348„ LAND SURVEYORS IsTe�``° 14 wo 0 SURVE �{ nn C) On 939 Main st. yarmouth, rya 02675 AR N OJALA, P.E., .S. DATE 1 "7—oI- Fo m...n.c►rioN C«v /16,00 t o 115 ii y l 1 3 3, a M 111 � r��0 /09 /07 C -- SArvO /o/ 99 . IJD 97 ,.. AJDTa 5 C— G T 1 O A.-I VC- R T SCi9LE- : / "_ /O MR�'Uf-TOLE 7`D l..J/TH/ill ` o---o--o—o-- proposed grour:d Prof'ire /2" OF F/til✓S'HEDr-�,E'ADE ("rr-tin. %4"p�r Cf� FL Ol.�/ -- - ----Pin- SCHED. ¢O VC. 0,e �8 par fGo'1i•) EQUAL TO $EPT�'f c P PC: ro 8E 3fg"pec`3"fan T.9-NK-• --� /.,o /,tJ_ G�7 vE r Fo,+z 4 14 92 LEVEL DIST• BOX . i 94 � 94 Jio \ion Jub io¢ 3 +2. `76 e8 go / �96 g6 I 3 � �4 � r A ,t- 9z ;washedsfo _. . 9s 96 9a O GAL. SEPTIC TAIVEG f Z SI rJb LEACH P1 r S T om- S o L C LOG l DA7-C-: y- J2-84 TE5T BY� Ar.FR6D Fvc�.GR M H O USE 1 _ - {'i"i e9 G I SIC--�3�T' � ... � �,, .,'T.,J E S S :-LOW R n, ,�L.4 Y 9� /- 2- /�7/^1.//ti/C H - ,�`" //0. T. H. 0-v - --�-80SE P7'/C TANk . 3,,3° USE: 100� Avv G.P.D. ,r „ ►�0 ' -' / d / / , \ �,\ �I A: BoTToM: 7815 X /10 7e�•5v / S.O 60 s-Tz- E_ SA�/v /"IDr .'.• 98 ^ /STun/E S 9 9,0 /3 2 /xoros�p / T,H. n/.,; D Pow 4 9810 /44 og /06 PROPOSED OAJ THE Gr20Ulv0 AS G, RAV El- )RtV Sl-lOInJI`J ON TN/5 PLAN.! DOES - co&IFO2/"I TO THE BUrLD/lvG �E-r ,S/ TEE - S E IAJ/9 G E PL A NJ C K . ,2E 0L)1.2EMENTv OF THE c�lnJ/V OF BARNS TApJ.. :FOR : L © Tf1 -� L. GP 39n72e OLD JAIL LAN E 1p OF M �� OF �,� �s �` BAR .N S T,q B G_� /N'�A, A. o GEORGE G� PA Ro PREPAREZ FOR:` -A V 1D Da�/E L L LOW. 2 807 vs 4100 Civt SCALE AS /V'OT�"-..D OATS: 2 2 J C4 A14- /98 7 ^ A / �-• A./ Z / } 8 PL./q A (SGALE: 1" • 9,0') V l C. W � l�C� 7s O pAT'E _ o. o o a xisf-/ n q a /e va.-J"-ion - BL D:G. SET�AGIC o.00 propvscd /oval /OrJ �EG?U/l2EMENT5 AFlo ?OtlEZ7 ' -�'r-O n t - . 3� _-Ff. .�" LO GJ � l.�I E L..L Ems, /n c. , - -- - -- — — q 30,4? 20 OF HEA4-71- SS• 7/4 /"li9/AJ zsreEET con�-ov�-s YFar2MOUfH PO' RT MPSS . 10, proposed c o n•f`ovrs rear 1 .5 , PQRE55lONAG. �rvGlh.�EEi25 LArI/D SUl2VEYGi,2S 87-