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Home My WebLink About0283 OLD JAIL LANE - Health 283�- Old Jail Lane Barnstable F } A= 277 023 i o a 0 TOWN OF.BARNSTABLE LOCATION�BL��II, Ly 4• SEWAGE# ZD VILLAG �ASSESSOR'S MAP&PARCEL 'Z, Z INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY. (type) f2 size) "t�3, `5 NO.OF BEDROOMS OWNER �� [ PERMIT DATE: 771 COMPLIANCE DATE: Separation Distance Between e: l I„ 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) + 100 Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY zl k c 501 I OT No. C? Fee t THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS ftplitation r Vspo8al 6pstrut Construction Permit Application for a Permit to Construct( Repair( ) Upgrade ) Abandon{ ) El Complete System Individual Components Location Address or Lot No. (� 1, Owner's Name,Ad ess,and Tel.No. Assessor's Map/Parcel Z d rf, G� �` Installer's Name Addre s,an T .No. Desi s N �Adldl�reSa,Tel, Gja •.Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.requi ed) gpd Design flow provided gpd Plan Date Number of sheets Re ision Date Title Size of Septic Tank L,26 IMA Type of S.A.S. Description of Soil , Natur Z,Re airs or Alterations(Answer w en appli ble) G 1AD 42COWD Date last inspected: Agreement: r 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 Environme4Codenot to place the system in o eration until a Certificate of Compliance has been issued by this Bo o lth Signed Date Application Approved by Date' Application Disapproved by Date for the following reasons Permit No._ Date Issued °w. No. � ' �'�./— �� Fee L/(� x THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS application f r biop sal 6pstem Construction Permit F Application for a Permit to Construct O, Repair( ) Upgrade ) Abandon( ) ❑Complete System Individual Components Location Address or Lot No. f �p-` 0 Owner's Name,Address,and Tel.No. Assessor's Map/Parcel �'.1 1- Z ! Installer's Name'Address,and T �.No. �,y „;l r} �` ` Designer's N _ e Address,_andtTel. o. j Type of Building: Dwelling No:of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) _ Other Fixtures Design Flow(min.required) __I gpd Fi 1 gpd Design flow provided '7`/ gpd t?: Plan r Date } �� ► Number of sheets Revision Date a, } Title 414 0 -fi(IC Size of Septic Tank C lE.�f.�) Type of S.A:S. f ' LO_. Description of Soil Nature'of Repairs or Alteratiiio4n�6s!y�(AAnswee�rl when applicable) Date last inspected: Agreement: The undersigned'agrees to ensure the construction and`mairitenance 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 Certificate of Compliance has been issued by thisBoard o''fNealth. ' y i Signed `� - . -_ Date l Application Approved by ��,`.;" .g Date Application Disapproved by Date for the following reasons Permit No. c� C, Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposallsysste�mlCoonsstructed( ) Repaired( 6�) Upgraded Abandoned( )by at �11. L,j+ has been constructed in accordance ooff�,,,,,,,, a7 6 with the provisions Jtof/Title 5 and the for Disposal System Construction Permit Nros�.�',��`-'�dated Installer �''✓'� �i..n Designer' I�'�i 4' �. L(Avt w #bedrooms _ Approved design flown ,(� � gpd The issuance of this permit shall not be construed as a guarantee that the system willrfu ction as designed. � � Inspector (11IAn`wrx t;Date No. Fee 40-� THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS IDisposal *pstern oustructiou'J)ermit Permission is hereby granted to Construct( ) Repair( ls) Upgrade Abandon( 1 System located at .,'° �r jO If d s described in the v to and,a: a abo a ppli_cahon for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction mustbe completed within three years of the date of this pe it. Date / /� �' c' Approved by -1 w Town of Barnstable , Via qo Inspectional Services = Public Health Division M" Thomas McKean,Director ho+,�ptb 200 Main Street,Hyannis,MA 02601 Office: 508-8624644 Fax: 508-790-6304 Installer& Designer Certification Form 7 Date: 'J Sewage Perm t# Assessor's Map\Parcel 17 Designer: ( 0% r'�� Installer: kowk Address: NJ Address: On �1 W v W w9ry was issued a permit to install a dat ) (installer) septic system at I based on a design drawn by address) n I/ dated (designer) I certify that the septic system referenced above was installed substantially...according to the design, which may include minor approved changes such as'lateral.relocation of the distribution box and/or septic tank. Strip out (if required) was inspected. and the soils were found satisfactory. . j r. a I certify that the septic,system.referenced above was installed with major changes (i.e. greater than 109,lateral relocation of the SAS or any vgrticaf ielocation of any component of the septic.,system) but*in;* rdance with State & Local Regulations. Plan revision or certified as-built by designer to follow. Strip.out (if required) was inspected and the soils were found satisfactory. I certify that the system referenced above was constructed in compliance with the to rms of the RA proval lett rs (i plicable) OFS4gs DAVID nstaller's ignature 8 ON ' A. rn t�do.1086 �f (Designer's Signature) (Affix. 4-0 Here) PLEASE RETURN TO BONSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL .'NOT BE ISSUED UNTIL BOTH THIS'FORM AND AS- BUILT CAR Y THE.BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. WoAdeptAHEALTMSEWER connecASEPTIODesigner Certification Form Rev 8-14-13.DOC I Commonwealth of Massachusetts U W Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form Not for Voluntary Assessments wM 283 Old Jail Lane Property Address Eliza Cox Owner Owner's Name information is required for every Barnstable MA 02630 11/14/1.3 page. City/Town State Zip Code Date of Inspection s Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. r Important:When filling out forms A. General Information on the computer, use only the tab s key to move your 1. Inspector: cursor- not use the return urn James Ford key. Name of Inspector b Company Name a: P.O. Box 49 Company Address Osterville MA 02655 City/Town State Zip Code 508-862-9400 S 12482 Telephone Number License Number I B. Certification i I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a;DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000).The,system: ® Passes ❑ Conditionally Passes ❑ Fails Needs Further Ev ation by the Local Approving Authority 11/14/13 Inspecto Signature Date The sy m 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. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspectioti does not address how the system will perform in the future under the same or different conditions of use. t5ins•3/13 Title 5 Offcial Inspection rm: ubsurface Sewage Disposal System•Page 1 of 17 i Commonwealth of Massachusetts Title 5 Officiat`l Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 283 Old Jail Lane Property Address Eliza Cox Owner Owner's Name information is required for every Barnstable MA 02630 11/14/13 page. City/Town iState, Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check 'A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 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. Check the box for"yes", "no"or"not determined" (Y,N, ND)for the following statements."If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): 4 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Mass''chusetts W Title 5 Officia;,l Inspection Form Subsurface Sewage Disposal;System Form -Not for Voluntary Assessments 1, 283 Old Jail Lane " Property Address Eliza Cox Owner Owner's Name information is required for every Barnstable MA 02630 11/14/13 page. City/Town ; State Zip Code Date of Inspection B. Certification (cont.Y ;!. ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally'passes (cont.): ❑ Observation of sewage�backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with! ;approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution boxi is leveled or replaced ❑ Y ❑ N ❑. ND (Explain below): 4' S I ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the.Board of Health):, ❑ broken pipe(s)'are:replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ' ❑ Conditions exist which'require further evaluation by the Board of Health in order to determine if the system is failing to!protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑. Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 ?' Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 I + Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal,System Form -Not for Voluntary Assessments ,M 283 Old Jail Lane Property Address Eliza Cox Owner Owner's Name information is required for every Barnstable MA 02630 11/14/13 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: "*This system passes if the well.water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates;absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: j .i D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" air,"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 ❑ 0 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official ;Inspection Form Subsurface Sewage Disposal'System Form -Not for Voluntary Assessments 283 Old Jail Lane ! Property Address I Eliza Cox Owner Owner's Name l 4 information is required for every Barnstable MA 02630 11/14/13 page. Cityrrown ;, State Zip Code Date of Inspection B. Certification (cont.), Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any q'(jrtion 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 systerh passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] 1 ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems,,you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No P t t ❑ ❑ 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'='1WPA)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 Secti n D above the large system has failed.The owner or operator of any large system considered a signif5cant 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. l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 I� r : Commonwealth of Massachusetts Title 5 OfficW, }Inspection Form '.System Form Not for Voluntary Assessments Subsurface Sewage Disposal;� M 283 Old Jail Lane i Property Address Eliza Cox ' Owner Owner's Name ! ; information is required for every Barnstable MA 02630 11/14/13 page. Cityfrown State Zip Code Date of Inspection C. Checklist l ; Check if the following have been done. You must indicate"yes" or"no" as to each ofthe following: Yes No ® ❑ Pumping informationwas provided by the owner, occupant, or Board of Health ❑ ® Were any-of the system components pumped out in the previous two weeks? ❑ ® Has the`system received normal flows in the previous two week period? El ® Have large volumes of water been introduced to the system recently-or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available`-note as N/A) ❑ Z Was the facility or dwelling inspected for signs of sewage back up? ® ❑ •Was the'site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size,and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information. Residential Flow Condition;: Number of bedrooms (design):` 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms)' 330. S . t5ins•3/13 f' ' Title 5 Official Inspection Form:Subsurface Sewage Disposal System+Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 283 Old Jail Lane Property Address Yi r Eliza Cox Owner Owner's Name information is required for every Barnstable MA 02630 11/14/13 page. City/Town i; State Zip Code Date of Inspection D. System Information Description: i . li F it S. i i . Number of current residents: : 0 I Does residence have a gar�iage grinder? ❑ Yes ®t No 1. Is laundry on a separate se.Nivage system?(Include laundry system inspection information in this report.) I. ❑ Yes ® No Laundry system inspected?! ` ❑ Yes ® No Seasonal use? Fi I t , ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Detail: unavailable Sump pump? l; ❑ Yes ® No Last date of occupancy: unknown Date Commercial/industrial Flow"Conditions: Type of Establishment: s Design flow(based on 310."CIVIR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No'. ' Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 F; _ i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 283 Old Jail Lane Property Address Eliza Cox , Owner Owner's Name (; information is required for every Barnstable MA 02630 '11/14/13 r page. Cityrrown R, State Zip Code Date of Inspection D. System Informatidn (cost.) Last date of occupancy/use:; ` date Other(describe below): General Information Pumping Records: Source of information: unknown Was system pumped as part of the inspection? ❑ Yes ® No t If yes, volume pumped: gallons j How was quantity pumped determined? Reason for pumping: Type of System: f Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool El Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP'approval.' ❑ Other(describe): l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Mas"Ochusetts = Title 5 Officil Inspection Form , Subsurface Sewage Disposal.System Form - Not for Voluntary Assessments ;M 283 Old Jail Lane Property Address Eliza Cox Owner Owner's Name information is required for every Barnstable " MA 02630 11114/13 page. Clty/Town i ._, State Zip Code Date of inspection- D. System Information. (cont.) Approximate age of all components, date installed (if known)and source of information: installed -5/14/02 - per as-built card Were sewage odors detectea:when arriving at the site? ❑ Yes ® No } F Building Sewer(locate on?site plan): Depth below grade: feet. Material of construction: ❑ cast iron ® 40,PVC ❑ other(explain): Distance from private water;supply well or suction line: ;j feet Comments (on condition of joints, venting, evidence of leakage, etc.): i Septic Tank (locate on siteiplan): a, Depth below grade: 1611 feet Material of construction: ® concrete ❑ m!etal ❑fiber lass 9 ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) El Yes ❑ No Dimensions: 1000 gals. Sludge depth: ;' 211 t5ins•3/13 it Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Officie Inspection Fora Subsurface Sewage Disposa System Form -Not for Voluntary Assessments y ,w 283 Old Jail Lane Property Address Eliza Cox Owner Owner's Name information is required for every Barnstable it MA 02630 11/14/13 page. City/Town State Zip Code Date of Inspection D. System Information '(cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness ; Distance from top of scum't§.top of outlet tee or baffle 6 i Distance from bottom of slum to bottom of outlet tee or baffle How were dimensions determined? t , Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): The cement tees were present.There was no sign of leakage.The inlet cover was 7" below grade. Grease Trap (locate on sir''; plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene Elother(explain): N/a 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 f I' Commonwealth of Massachusetts W Title 5 Official .'Inspection Form Subsurface Sewage Disposal . ystem Form -Not for Voluntary Assessments f 283 Old Jail Lane .. Property Address 1: Eliza Cox Owner Owner's Name information is required for every Barnstable MA 02630 11/14/13 page. City[Town State Zip Code Date of Inspection D. System Information (cont.) t Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): . ;f 4 i" Tight or Holding Tank(taQk must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): N/a Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: I Date 3 , Comments (condition of alarm and float switches, etc.): l I, 'Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 k ; I t ;V,k Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 283 Old Jail Lane Property Address l Eliza Cox Owner Owner's Name information is required for every Barnstable ? MA 02630 11/14/13 page. City/Town State Zip Code Date of Inspection D. System Information' (cont.) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above'outlet invert even 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.): The D- box was normal. ' { i- Pump Chamber(locate on,'site plan): Pumps in working order: ' ❑ Yes ❑ No* Alarms in working order: 7; ❑ Yes ❑ No* Comments (note condition of"pump chamber, condition of pumps and appurtenances, etc.): N/a R a 1. . " If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System.(SAS)(locate on site plan, excavation not required): If SAS not located, explain why: i-- l5ins•3113 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts W Title 5 Officiel` Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 283 Old Jail Lane Property Address Eliza Cox Owner Owner's Name information is required for every Barnstable MA 02630. 11/14/13 page. City/Town r State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits' number: a® leaching chambers number: 3-500 gal.10'x33.5'x2' ❑ leaching galleries number: ' a ❑ leaching trenches number, length: ❑ . leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name t f technology: Comments (note condition of soil, signs of hydraulic,failure, level of ponding, damp soil, condition of vegetation, etc.): The chambers were dry and clean.There was no signs of failure. A camera was used for the inspection. Cesspools (cesspool must.be pumped as part of inspection) (locate on site plan): Number and configuration N/a Depth-top of liquid to inlet invert Depth of solids layer Depth of scum layer f. Dimensions of cesspool w Materials of construction Indication of groundwater inflow ❑ Yes ❑ No I+ t t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17- } , 1 " .,F Commonwealth of Masa`achusetts A Title 5 Official` Inspection Form { Subsurface Sewage DisposaC System Form -Not for Voluntary Assessments M 283 Old Jail Lane Property Address Eliza Cox Owner Owner's Name information is required for every Barnstable MA 02630 11/14/13 page. Cityrrown State Zip Code Date of Inspection D. System Information. (cont.) Comments (note conditionfof soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): . It •S 'i Privy(locate on site plan):;! Materials of construction: Dimensions Depth of solids Comments (note condition{of.soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): N/a 4: i t t u t. t t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 i Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for VoluntaryAssessments ents 283 Old Jail Lane Property Address Eliza Cox ; Owner Owner's Name ' information is required for every Barnstable MA 02630 11/14/13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal,System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: rt ® hand-sketch in the area below ❑ drawing attached separately t. �roA_ r; i g' I G r e. ,D srok ��rive,wu I 0 1 0 y 3 c a 3yo34 y 43 3q t5ins•3/13 { r Title 5 Cfficial Inspection Forth:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official] nspection Form Subsurface Sewage Disposal'System Form -Not for Voluntary Assessments M a 283 Old Jail Lane r; Property Address Eliza Cox Owner Owner's Name information is Barnstable t MA 02630 11/14/13 required for every - page. Cityrrown to State Zip Code Date of Inspection D. System Information (Cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells c Estimated depth to high ground water: e0et Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from!system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: Using topo and water contours maps ❑ Checked with focal excavators, installers -(attach documentation) ❑ Accessed USGSdatabase-explain: You must describe how you established the high ground water elevation: see above A , 1 . Before filing this Inspection Report, please see Report Completeness Checklist on next page. l5ins•3/13 s Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 • Commonwealth of Massachusetts W Title 5 Officiaf Inspection Form Subsurface Sewage Disposal`System Form -Not for Voluntary Assessments `wM 283 Old Jail Lane Property Address Eliza Cox Owner Owner's Name t' information is t required for every Barnstable MA 02630 11/14/13 page. City/Town State " Zip Code Date of Inspection E. Report CompleterJess Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file 4. r r' 1 a , y ' i t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 =- TOWN OF R. -RNS'nABLE 40l LOCATION'73 /L Lam/ SEWAGE # o?k�® - S N7.LLAGE ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. 1,-1,92ra SEPTIC TANK CAPACITY Upo eoz- r' LEACHING FACIL=: (type)5,a 6! IX&or j 3) (size) %D 7 f' ',0 NO:OF BEDROOMS BUILDER OR WNER PERMTTDATE: e/—/&-9,2---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) ' /5_® 4 Feet Edge of Wetland and Leaching Facility(If.any wetlands exist within 300 feet of leaching facility) '"� Feet Furnished by Co At 00 _ _ a t �s r L -a77L No. � Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: _�V Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Zipplitation for 33izpozal *p$tem Con!Arurtian Permit Application for a Permit to Construct( )Repair(v/)Upgrade( )Abandon( ) ❑Complete System L✓J Individual Components Location Address or Lot No. Owner's Name,Addressand Tel.No. 63 0/0' t ;'a_ Assessor's Map/Parcel /�, �— l„/® Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: q��s Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ® Other Type of Building e— Rio.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 1 1,1112 gallons per day. Calculated daily flow 6_4360 gallons. Plan Date Number of sheets Revision Date Title J ) 4 2 2t7i7g - Size of Septic Tank �� .�.Y%�s7`1�9 Type of S.A.S. �p Description of Soil 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 by t 's B ar f FlAalth. Signed Date f ®y Application Approved by ` Date � G Application Disapproved for the following reasons Permit No. 2 U 0 1 �t-�� Date Issued No. Fee ,. THE COMMONWEACTH OF MASSACHUSETTS Entered in computer: { - `h , �,. ! Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTAB�LE., MASSACHUSETTS Application for Dizpaal *pztem Con5t uffion Permit Application for a Permit to Construct( )Repair(v/)Upgrade( )Abandon( ) ❑Complete System LJ Individual Components Location Address or Lot No. Z_ �/ca Owner's Name,Address and Tel.No. �'3' d �� , Assessor's MapTarcel $ Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. -7 7/- Jfa Type of Building: Dwelling No.of Bedrooms ,, ,�,,QQ Lot Size 7 sq.ft. Garbage Grinder(/1kd h Other Type of Building ;weoe vo.of Persons Showers( ) Cafeteria( ) Other Fixtures •` 4 Design Flow , 1112 gallons per day. Calculated daily flow® gallons. Plan Date Number of sheets Revision Date Title S �`�' aX 40 g �J G� 4, 4! Size of Septic Tank ��G�` ,L�i�'/S�` 19 Type of S.A.S. Description of Soil Q`y Vials Nature of Repairs or Alterations(Answer when applicable) i t 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 by t. s B ar f alth. Signed Date �G- Application Approved by tey KI &CL Date c / G I 'Application Disapproved for the following reasons Permit No. 0002 Date Issued --------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (Certificate of (Compliance THIS IS TO CER,T�j,FY, that the On-site Sewage�jDisposal System Constructed( )Repaired ( A/�Upgraded( ) Abandoned( )by C�OV/ O' G° AWE 9 7, at _913 e/C..� --,& / /0 . has been constructed in ccordance with the provisions of Title 5 and the for Disposal System Construction Permit No. o?Go 2 dated Installer Designer The issuance of this permit shall not be construed as a guarantee that the system will function as designed. Date //,q !n c�— Inspector ;�l 4� Q ( [C_U j i No. -------------------------Fee THE COMMONWEALTH OF MASSACHUSETTS- PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS Dizpoal *p5tem (Construction Perron Permission is hereby granted to Construc ( �LRepair(V/,Upgrade( )Abandon System located at �� ✓Gl'/�� /� Q"/��9�.5�`�l� �//L�� ' 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:Cons7uct7., must be completed within three years of the date of hsT ernk'tDate: , Approved by rp�1 TOWN OF N TABLE LOCATION,83 uL—j T/L Laf SEWAGE # 4492. If 'QUAGE v5444- ASSESSOR'S MAP & LOT 2 Q23 INSTALLER'S NAME&PHONE N0. dh-tr� � ��ys/i'C C/oY-�9?L SEPTIC TANK CAPACITY �do-0 LwG a LEACHING FACILITY: (type)5ev r! l`iowLi ill (size) fDAI T I S +AeF 1 NO.,OF BEDROOMS BUILDER OR WNER ` PERMTTDATE: y/6-g.� COMPLIANCE DATE:. 5 U E - Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility g Feet Private Water Supply Well and Leaching Facility (If any wells exist Feet on site or within 200 feet of leaching facility) f�O Edge of Wetland and Leaching Facility (If any wetlands,exist w of within 300 feet of leaching facility) Feet Furnished by k)&-y4J CcrOe qs yd .` a P 1 23 TROY WILLIAMS ✓ I� /v SEPTIC INSPECTIONS RECEIVED Certified by MA Department of Environmental Protection (508) 385-1300 19 Hummel Drive MAR 2 12002 South Dennis, MA 02660 TOWN OF BARNSTABLE COMMONWEALTH OF MASA&WV�- ' EXECUTIVE OFFICE OF ENVIRONMENTAI,AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION FAI UDaorECTION TITLE 5 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION PropertN Address: 283 Old Jail Lane Barnstable,MA Owner's Name: Benjamin&Beverly Jones Q Owner's Address: P. O Box 341 Barnstable,MA 02630 Date of Inspection: March 12,2002 Name of Inspector: Troy M. Williams Company Name: Troy Williams Septic Inspections Mailing Address: 19 Hummel Drive South Dennis,MA 02660 Telephone.Number: (508)385-1300 CERTIFICATION STATEI\IEN"T 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. 1 am a DEP appros cd system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The sv�tenv Passes Conditionall.- Passes Needs Further Evaluation by the Local Approving Authorit) Fails Inspector's Signature: & Date: .3 IltZ /6 z The system inspector shall submit a copy of this inspection report to the Approving Authority(13oard of I lealth 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.l his 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 pace I Page 2 of 1 I OFFICIAL INSPECTION FORM-=NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 283.01d Jail Lane Owner: Barnstable,MA Date of Inspection: Benjamin&Beverly Jones March 12,2002 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 a of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria no valuated 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 He h,will pass. Answer yes. no or not determined(Y,N,ND)in the for the following statements. If- t determined"please explain. The septic tank is metal and over 20 years old* or the septic tank(whethe etal or not)is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imm' ent. Svstem will pass inspection if the existing tank is replaced with a complying septic tank as approved by the and of Health. *A metal septic tank will pass inspection if it is structurally sound,not aking 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 tgh static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or en distribution box. System will pass inspection if(with approval of Board of Health): broke ipe(s)are replaced ob ction is removed tstribution box is leveled or replaced ND explain: The system re tred pumping more than 4 times a year due to broken or obstructed.pipe(s).The system will pass inspection if rth approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 f Page 3 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 283 Old Jail Lane Owner: Barnstable,MA Date of Inspection: Benjamin&Beverly Jones March 12,2002 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 C 15,303(1)(b)that the system is not functioning in a manner which will protect public health,safe 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 wetlan or a salt marsh 2. System will fail unless the Board of Health(and Publ' Water Supplier,if any)determines that the system is functioning in a manner that protects the pu c health,safety and environment: The system has a septic tank and soil abso on system(SAS)and the SAS is within 100 feet of a surface water supple or tributary to a surface ter supply, _ The system has a septic tank and S and the SAS is within a Zone I of a public water supply. The system has a septic tank d SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic k 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 " the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volati organic compounds indicates that the well is free from pollution from that facility and the presence of monia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteri are triggered.A copy of the analysis must be attached to this form. 3. Other: 3 �'I Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 283 Old Jail Lane Barnstable,MA Owner: Benjamin&Beverly Jones Date of Inspection: March 12,2002 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No _ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool 1/ 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. _ &Zj Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _ N/,g Any portion of a cesspool or privy is within a Zone 1 of a public well. _ gZj Any portion of a cesspool or privy is within 50 feet of a private water supply well. _ L/d 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.] `DES (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 Systems: To be considered a large system the system must serve a facility with a design ow of 10,000 gpd to 15,000 gpd• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria a ve) yes no the system is within 400 feet of a surface drinking wat supply the system is within 200 feet of a tributary to a s face drinking water supply the system is located in a nitrogen sensiti area(Interim Wellhead Protection.Area—IWPA)or a mapped Zone 11 of a public water supply well If you have answered"yes"to any questio in Section E the system is considered a significant threat,or answered . "yes"in Section D above the large syst has failed.The owner or operator of any large system considered a significant threat under Section E or iled under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner shoul ontact the appropriate regional office of the Department. 4 Page 5 of 1 I OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 283 Old Jail Lane Owner: Barnstable,MA Date of Inspection: Benjamin&Beverly Jones March 12,2002 Check if the following have been done. You must indicate"yes"or"no"as to each of the followins: Yes No !'.:;:,ping information was provided by the owner.occupant. or Board of I Icald, __ ✓ 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) v _ 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? _ War(s 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)J 5 Page 6 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 283 Old Jail Lane Owner: Barnstable,MA Date of inspection: Benjamin&Beverly Jones March 12,2001PLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 3 Number of current residents: 2 Does residence have a garbage grinder(yes or no): No Is laundn on a separate sewage system (yes or no): Na [if yes separate inspection required] Laundry system inspected(yes or no):�q Seasonal use:(yes or no): My Water meter readings, if available(last 2.years usage(gpd)): Sump pump(yes or no): 14a Last date of occupancy: COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no): Zy . Non-sanitary waste discharged to the Title 5 system _ Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: l U 5. it 74 /o t Was system pumped as part of the inspection(yes or no): wo 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: 1;" I2-/30 /1 t t 4, Were sewage odors detected when arriving at the site(yes or no):�[o 6 Page 7 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 283 Old Jail Lane Owner: Barnstable,MA Date of Inspection: Benjamin&Beverly Jones March 12,2002 BUILDING SEWER(locate on site plan) Depth belo�s grade: /g',4 Materials of construction:_cast iron -./--40 PVC_other(explain): Dktanc e from private water supply well or suction line: N Comments(on condition of joints, venting,evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade: ( ' 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: C 11.1 Sludge depth:' Ll Distance from top of sludge to bottom of outlet tee or baffle: f3 Scum thickness: , oAg Distance from top of scum to top of outlet tee or baffle: Distance fi-om bottom of scum to bottom of outlet tee or baffle: _c,�� How were dimensions determined: P,.o 1, - . _ Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc.): NO !_.., (Q c... �,� � �l L c.(�Gti.. -� o,� � c` �'.,a S•t ,..�c:.. S �,..�-.�. GREASE TRAP:_(locate on site plan) Depth below grade: Material of construction:_concrete_metal_fiberglass_polye ene_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 outleZteeor ffle: Date of last pumping: Comments(on pumping recommendations,inlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leaka ,etc.): 7 f Page 8 of 11 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 283 Old Jail Lane Owner: Barnstable,MA Date of Inspection: Benjamin&Beverly Jones March 12,2002 TIGHT or HOLDING TANK: (tank must be pumped at time of pection)(locate on site plan) Depth below grade: Material of construction: concrete metal fibergI _polyethylene other(explain): Dimensions: Capacity: gallons Design Floe gallons/day Alarm present(yes or no): Alarm level: Alarm in working eL Date of last pumping: Comments(condition of alarm and at switc 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.): - 6 K l O L e- , A V� -f-*�.ti � c��, a 1 c u..c�r'. {� �- J7- (3 u�... w: �I � ✓�,� � c.e..� iM hL/� cQc5 � 5,h 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,condition Wpumps and appurtenances,etc.): 8 Page 9 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 283 Old Jail Lane Owner: Barnstable,MA Date of Inspection: Benjamin&Beverly Jones March 12,2002 SOIL ABSORPTION SYSTEM(SAS):_3,/ (locate on site plan,excavation not required) If SAS not located explain why: Type Teaching pits, number: I _ x C L `/'S 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.): � V r /✓. S _� ' L�J.?- T [.✓ 1 4✓ti/� N� I h G. JYO CESSPOOLS: (cesspool must be pumped as part of inspection)(lo to on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum la\er: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes o>no): Comments(note condition of soil,signsdraulic 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 hydrauli /ailure, evel of ponding,condition of vegetation,etc.): /X Page 10 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 283 Old Jail Lane Barnstable,MA Owner: Benjamin&Beverly Jones Date of Inspection: March 12,2002 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. A OI rno,fal/�ti 33 '4" Inc 11 i S lU Page 1 1 of 1 1 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 283 Old Jail Lane Owner: Barnstable,MA Date of Inspection: Benjamin&Beverly Jones March 12,2002 SITE EXAM Slope V1, Surface water Check cellar Shallow wells Estimated depth to ground water 50 t- '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) Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: k17, �- / o Uea- f--e. ---f F� �•, e;vti�/ A w L G ISO V�..�l � �c-r �w fo J o 7n b....,�n � �z b [[.. � [s o -�S /r h, a, T Z- �/r��ti.,� ,��.t„J-e.✓ o. 11 THE COMMONWEALTH OF MASSACHUSETTS , l BOAR® OF HEALTH . J I TOWN OF BARNSTABLE Appliration for Bitipusa1 Works Toustrurtiun Vamit �J ; Application is hereby made for a Permit to Construct (+--*) or Repair ( ) an Individual Sewage 'Disposal v System at: ...Ze T '"/O ..........._........_ ---.. ... ....................................... Location-Address or Lot No. - T.4�i.v :Ta.v s .................. ............................................... Address aF. 1. .� : ..............•----.• Installer Address 2 87/ls Q Type of Building Size Lot_...-__....................Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building a Other—Type g ____________________________ No, of persons............................ Showers ( ) — Cafeteria ( ) QOther fixtures ------------------------• ----------------------------.-------•-••--•--•-•-•--•-••---------........................................................... W Design Flow............-`_-5 .........................gallons per person per day. Total daily flow:._._____.330________......._._.___gallons. WSeptic Tank—Liquid Zr capacitv .gallons Length._��... __.... Width . ��__ Diameter................ Depth-4' �._. x Disposal Trench—No_____________________ Vidth.................... Total Length................, ..._ Total leaching area....................sq. ft. Seepage Pit No........./......... Diameter...... __..... Depth below inlet.......6._.._._._. Total leaching area...3�9__�.sq. ft. Z Other Distribution box ( ) Dosing tank ( ) '-' Percolation Test Results Performed by........4erPW1,)7,F-0.......�..._._!. ._. a Test Pit No. 1....L_---____minutes per inch Depth of Test Pit.... ....... Depth to ground water........................ fZ4 Test Pit No. 2.....4.Z._minutes per inch Depth of Test Pit..... Depth to ground water...... ............ P4 ••-•----•---•---••---•-------••-----•-•-•••----•••-•-••-------------••---.........._.. ----------------- . O Description of Soil......G��_-Y�".._Woe,o9e& =SoIG 3L"_ ---------------•-••-•------------------••-•••-•----•- ►�i Go=/Z0_`�__..�—ric/L .$,q��J $` STD.el� /20~— /SZ�` �IGSD/ S-eCYa-/9 /fir-D (� - - ••------------ -----•----•-•-------------•-----------------------•----------•--------- 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 Environmental Code—The der gned further agrees not to place the r_. system in operation until a Certificate of Compliance/S , issu t e board of health. Signed --- =................ .............................'--"......-'---..-..-..-- /..IJate Application Approved By .............--- ----- ' j .�-�. ..-..g/ t ............................................................................ Date Application Disapproved for the following reasons- -------- ---------------------------- -----------------------------•---.------------------.----....------.. .......------------ -------------------- ------------------ ------------------- C Dare PermitNo. S --------------------=------- Issued to .............................. Date No ... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliration for Bisposal arks Tonstrnr#inn Frrmit Application is hereby made for a Permit to Construct (&�-) or Repair ( ) an Individual Sewage Disposal System at: --- ----...-• -.......... ......................................... ..........•------•-------•..........-----•-•--• •---..............----•-•-------...............•- �. Location-Address or Lot No. t3.-wTA•�,`"'-• -- v -►�-------------------------------------- -----------�-% �,�sr t.�.. ................................................ r ^ Owner )~ Address ,-� — ---------=I 1 +��...------ .:)----- ...................... .................................................................................................. Installer Address d Type of Building Size Lot.. - 7S.Sq. feet V Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) p, f Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) P I Other fixtures ---------------------------------------------••••. .••-- W Design Flow..............5;r.......................gallons per person per day. Total daily flow..........-330.......................gallons. c WSeptic Tank=Liquid capacity_?�4Fgallons Lengtht�Lp.A.... Width...4Ep--•. Diameter---------------- Depth..¢_8.._ x Disposal Trench—No..._......'_....:.r. Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage-Pit No.........Z........ Diameter.......1Z!_._. Depth below inlet....... ....... Total leaching area...33!3.sq. ft. Z Other Distribution box ( ) Dosing taiik'(-\ ) t '� ,, Percolation Test Results Performed jby........ w .......�-....X--- Date... 7%%5 �..__. ,`ia Test Pit No? 1....0 z'...minutes per inch Depth of Test Pit....e- '.... Depth to ground water........................ Li, Test Pit No. 2-----4.Z..minutes per inch Depth of Test Pit.....ZA!`.... Depth to ground water........................ a ------------------------------------------------------------------------------------------------- O ---Deicription of Soil..... "'... !!� ...{ .3'vi _S®� 34":4c•!' r/=-r v� S'4A-O x tC�►" /�0� =r.vLs �-, a V .......................................................•-•••-••••------•-•-•-•-•-••-•...---•..........-••-•.................................�•-•-•-•••-•-••-••-••-•-••-•............................-- W S'77�N 3 1% 1 ----••---------------------------------•------•------------•---------•---------•--•---....-----••••----••-•-••••-•---••---.:----•-••-•-•-•--••-••-•••-•--•------••.........--••-••---••-•••-••--•----... U Nature of Repairs or Alterations—Answer when applicable_.`. . ............:.....................'_._._. ...................................... Y Agreement: L ' The undersigned agrees to install the aforedescribed Individual Sewage Disposal,System in accordance with the provisions of TITLE 5 of the State Environmental Code=Theme u•dersigned furher agrees not to place the system in operation until aCertificate-of Compliance has been issued by, board of-health. ' r�,. �� 9 Signed ' t,../�- • , C/' i / / Date..--...._-... Application Approved By ............... � .. .. .,-� ,�-=.-t�..-: :....... ..... ...../ _.. - Date Application Disapproved for the following reasons: ...................... ------------.............---•--.................................................................. --------- ..----° ------ -- ---------------------- ---- ----------------------------------------------------------------------------------------------------------------------- ------------------------------------ -- ' Permit No. ...q/........ �� Issued ---------------------= =..........Date .. Date THE COMMONWEALTH OF MASSACHUSETTS ��r BOARD OF HEALTH TOWN OF BARNS`T'ABLE Tertift.cttte';nf,`(1�omplinuric THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( V<or Repaired ( ) by----------------------------------------------------- --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- �- Installer at --------- .�.�-...----1.0........ .......... -(.. .........: �......�_.... .. .......1 �.nr��aQ --•------------------------------------------------- ------ has been installed in accordance with thepr v'isions of TITLE 5 of The State Environmental Code as described in 'r' ...... ,'/ d _ dated ..........•------------------- the application for Disposal Works Cons`truI,---I {Permit No. y.....,� ............. . _.. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONST UED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY U 0 DATE.. Inspector ....----.., .:.. ......- ---> ................. p .�.�..�,.-- l I �, / �`- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH NO...d.�'��?•- TOWN OF BARNSTABLE FEE....4 �n Uisposa1 Works 0-1Cuns#rmuot. "plami# Permission is�hereby granted-------------------------•----.........------..•-•-••--•••-•.................. ✓) ...........................................................•--- to Construct ( or Repair an Individual Sewage Disposal System �-•0 at No..........: ... ........�......t o .... .. . .......1 � .ai?!........................................... :r Street A/��/.as shown on the application for Disposal Works Construction Permit ,No....:.:..-. Dated.......................................... �..-- � � \ Boa DATE.................................................................•-•••-•........ � l Board f Health FORM 36508 HOBBS Et WARREN.INC..PUBLISHERS t+ TOWN OF LOCATION /0 �� ( L- SEWAGE # q/—Q!5� VILLAGE , ,., ASSESSOR'S MAP 6� LOT ( -O ..aZINSTALLER'S NAME 6z PHONE NO. .,. ��a SEPTIC TANK CAPACITY %3``6-'rO LEACHING FACILITY:(type)_Le r (size) NO. OF BEDROOMS .� PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER al', z r l DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No :: �r �� — Q �, l w D�� a (.b• r -----76 - Fee----2-'-1------------ BOARD OF HEALTH Y. , TOWN OF BARNSTABLE r� ��f�cation,�'or�efr �Lortgtructaor��ermit Applica ion is hereby made for a permit to Construct ( ), Alter ( ), or Repair ( )an individual Well at: ------------------- ^ Location — Address Assessors Map and Parcej e�ti/ �il'Ir�/_- U�ir5 - - _ -'6 ' �_ � G %�i /r m_-------1W'4 ---------------------- / /Owner Address t��o2a' ��LCe---��=lc� � /t914-------- --------- -------------- ----- ------ --------- Installer — Driller ddress Type of Building Dwelling - - - — - ----------------------- Other - Type of Building------------------------------------- No. of Persons----------------------------------------------------------- Type of Well- Q - - Purposeof Well----------------------------------------—----------------------- Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protectio Regulation.— The undersigned further agrees not to place the well in operation u Il r ' icate p " e has,been issued by the Board of Health. O� ate ApplicationApproved By------------------------------------------------------------------------------- ----------------------------------- date Application Disapproved for the following reasons:------------------------------------------------- ------ ----------------------------------------------------- ---------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------- date PermitNo. --7�------ ------------------------------ Issued----------------------------------------------------------------------------------- date BOARD OF HEALTH TOWN OF BARNSTABLE Certificate ®f �ompriance THIS IS TO CERTIFY, That the Individual Well Constructed �4, Altered ( ), or Repaired ( ) bY- ac� --------------------------------------------------------------------------------------------------------------- Installer -------b-Q1-----I-'o------oi -------- ` ------------------------------------------ has been installed in accordance with t e provisions of the Town of Barnstable Board of Health Private Well Protection Regulation as described in the application for Well Construction Permit No. -laml=__7 ___Dated---------------------------- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE--------------------------------------- -------------------------------------- Inspector--------------------------------------------------------------------------------- - =�-` !---� - - - ----------No.- Fee-- BOARD OF HEALTH TOWN OF BARNSTABLE Application for Vell Con.5truct ion 3permit Appl}'ca ion is hereby made for a permit to Construct (X), Alter ( ), or Repair ( )an individual Well at: L /13 13� _TV,� G r/ ------------------------------------------------- - - — — — ........ ----------- —-------------------------- --------------------------------------------------------- Location — Address Assessors Ma and Parcel --------------------------------------------------------------------------------------- - ----------------------------------------------------- -------- Owner Address a - k_ 3� SQL �i7o �i� -------------- —Installer 7 Driller (Address Type of Building Dwelling--��-`�-�a------------------------------------------------ Other - Type of Building-------------------------------------- No. of Persons__, ` — ------------------------------ Type of Well-F��- ""=v -- Capacity - - --------------------------------------------------- Purposeof Well------------------------------------------------------------------- Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation — The undersigned further agrees not to place the well in operation until a/Ce�r Certificate of.0 - p i"e has been issued by the Board of Health. �fvl � �aL � � Signed --- - �� 1'_____'___ J � � date ApplicationApproved By------------------------- - -- ------------------------------------ ---------------------------------------- date t Application Disapproved for the following reasons:-------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------ -------------------------------------------------------------------------------------- date PermitNo.------ /6----------------------------------------- Issued--------------------------------------------------------------------------------- date BOARD OF.HEALTH TOWN OF BARNSTABLE - Certificate (Of (Compliance ' THIS IS'•TO CERTIFY, That the Individual Well Constructed �4, Altered ( ), or Repaired ( ) by------------ ,�r- -—1 ��" ------------------------------------------------------------------------------------------------------------------ ------------------ Installer ca�----j - I -- - ------------------------- has been installed in accordance witk provisions of the Town of Barnstable Board of Health Private Well Protection Regulation as described in the application for Well Construction Permit No. IIA1 A---Dated--------------------------- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE--------------------------------------------------------------------------------------- Inspector------------------------------------------------------------------------------------ BOARD OF HEALTH TOWN OF BARNSTABLE Yell Con5tructionpermit No. -- ��---- Fee--- -- Permission is hereby granted----------�- 4� ------W &-------� V - ------------------------------- to Construct /('`),-yAlter ( ), or Repair, ( ) an Individual Well at: No. ------------`'" `' / — Q — —t y! = ` 1 Street f cCak�i l[►�(- _!--------------------------------------------------------------- as shown on the application for a Well Construction Permit —---------------------------- Dated----- 2,v �_-_�_ -5�/- ----- ------- ---- ---- -------- --------- ---------------- -- ---1`-1l)-------------------------------------------- (Board of Health DATE------------------------------------------------------------------------------- O+!mnrnrtnnnntnrnnrrnnnrnrmrnnnnrrnrnrrrrmnnnnrnnnrrtnrmmnrrrni?rrrrmrnnnnrrnnnrnrn►rrnmrrrrnnnnnnnttrmnrrnntrrrnnrnrrrnmrtntrrmmm�mmrinrmmnrnrnti,,� BE ENVIROTECH LABORATORIES Mass. Cert.#:MA063 449 Route 130 Sandwich,MA 02563 (508)888-6460 _ x: CLIENT: Benjamin Jones LOCATION: . Lot 10 Old Jail Lane ADDRESS: 21 ummaqui Barnstable, MA E COLLECTED BY: Fred ClittordSAMPLE DATE: 1-6-92 TIME: 12n E: DATE RECEIVED`— SAMPLE ID: 7 JOB rr: New Well _ WELL DEPTH: 100, RESULTS OF ANALYSIS: Parameter Units Recommended limit Result Coliform bacteria/100 ml (MF Method) 0 0 pH pH units 6.0-8.5 6.38 ' Conductance umhos/cm 500 79 Sodium mg/L 20.0 9.7 Nitrate-N mg/L 10.0 0.03 Iron mg/L 0.3 <0.05 iF l=: Manganese mg/L 0.05 Hardness mg/L as CaCO 3 500 Sulfate mg/L 250 R Potassium mg/L 20.0 Alkalinity mg/L 200 Chloride mg/L 250 Turbidity NTU 5.0 Color APC units 15.0 c Background bacteria COMMENT: EPA 601/602 # ug/L Chloroform= 2 *see attached sheet � S NO WATER IS SUITABLE FOR DRINKING PURPOSES FOR PARAMETERS TESTED. DATE 412- lliltllltlliUllllUllllilUUIIUUIUUIUUIllIl11111UU1111UU1111i1U111111U11illlllllllllUltllltlill!!lliiill►111i11i1111►1t11lllitliilllllilltltlitltt 111lllUtl!!t{UUllllUt11l1tUUllU111lIIllUllllilllU!!llllilltlt111�� I +�1 GROUNDWATER �t ANALYTICAL EPA METHODS 601 and 602 Volatile Organics (GC/PID/ELCD) Field ID: ET-807 Lab ID: 2484-01 Project: Jones Old Jail House QC Batch: VGA-913 Client: Envirotech Laboratories Sampled: 01-06-92 Cont/Prsv: 40ml VOA Vial /NaHSO4 Cool Received: 01-08-92 Matrix: Aqueous Analyzed: 01-14-92 PARAMETER CONCENTRATION REPORTING LIMIT (ug/L) (ug/L) Dichlorodifluoromethane BRL 5, Chloromethane BRL 1 Vinyl Chloride BRL 1 Bromomethane BRL 5 Chloroethane BRL 1 Trichlorofluoromethane BRL 1 l ,l-Dichloroethene BRL 1 Methylene Chloride BRL 1 trans-1 ,2-Dichloroethene BRL 1 1, 1-Dichloroethane BRL 1 cis-1 ,2-Dichloroethene * BRL 1 Chloroform 2 . 1 1 , 1 , 1-Trichloroethane BRL 1 Carbon Tetrachloride BRL 1 Benzene BRL 1 1 ,2-Dichloroethane BRL 1 Trichloroethene BRL 1 1 ,2-Dichloropropane BRL 1 Bromodichloromethane BRL 1 2-Chloroethylvinyl Ether BRL 1 trans-1 ,3-Dichloropropene BRL 1 Toluene BRL 1 cis-1 ,3-Dichloropropene BRL 1 1 , 1 ,2-Trichloroethane BRL 1 Tetrachloroethene BRL 1 Dibromochloromethane BRL 1 Chlorobenzene BRL 1 Ethylbenzene BRL 1 m+p-Xylene * BRL 1 o-Xylene * BRL 1 Bromoform BRL 1 1 , 1,2,2-Tetrachloroethane ' BRL 1 1 ,3-Dichlorobenzene BRL 1 1 ,4-Dichlorobenzene BRL 1 1,2-Dichlorobenzene BRL 1 QC SURROGATE COMPOUND SPIKED MEASURED RECOVERY QC LIMITS Bromochloromethane 30 31 103 % 83 - 117 % Fluorobenzene 30 30 100 % 87 - 113 % BRL = Below Reporting Limit. * Non-target compound. "Trace" indicates probable presence below listed Reporting Limit. Method References: Method 601 - Purgeable Halocarbons and Method 602 - Purgeable Aromatics, 40 C.F.R. 136, Appendix A (1986). r TOWN OF I " . LOCATION L CAT10N _�O G 17 SEWAGE.#: VILLAGE , � f� ASSESSOR'S MAP 6& LOTAZ77-00... INSTALLER'S NAME & PHONE NO.-, SEPTIC TANK CAPACITY LEACHING FACILITY-Atype) (size) /C .. x4t NO. OF BEDROOMS _PRIVATE WELL OR PUBLIC WATER 1 BUILDER OR OWNER e+L r N DATE PERMIT ISSUED: r- DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No - " j:. v is•' ;.' { ,' APPLICAT.fOrl FOIL U0L)J VA_Ciu6 i,_LTL LOCATION UG-9 ✓, /c- Z117✓V45-- NO. -78 2 ,p VILLAGE DATE s y APPLICANT FEE��o) ADDRESS Gc��iy,.�¢von , P TELEPHONE NO. (Non-refundable) ENGINEER Gib.! ap Jle=Z[_1�}/' TELEPHONE 'NO. 3CZ-2z46, DATE SCHEDULED 067� 45— (Applicant' s sig ature) ASSESSOR'S MAP & LOT NO: 2--77 / -Pe—C&-r- a SOIL LOG SUB-DIVISION NAME 4,y-�-No 4?v4,,/07' 7Z !Q DATE 067- /6; 4%7,f/ TIME /u'ao 19-1-7 EXPANSION AREA: YES__NO ✓,�✓wi� -Z G` _ENGINEER TOWN WATER i/ PRIVATE WELL ,/ OARD OF HEALTH EXCAVATOR SKE`1'CII: (Street name, etc. ,dimensions of lot, exact 'location of test holes and percolation tests, locate wetlands in proximity to test holes ) NOTES : /0 , 30 rf lei a � 1100,40 i � • 4 to .. ��'�� ;'Q.`�oo is 426.0 %%.-. S 46p�V 15" W o� �i/V�� 4/14 PERCOLATION RATE: TEST HOLE NO: f ELEVATION: TEST HOLE NO: � ELEVATION: 1 et✓® v�Lo�n'P . 1 �coov®�vs9�'J 2A 2 3 zz j> &eSo/z- zJ /rt1 P1 - 4 � 4. 51 5 _ -- - - �/�Y��S O 'r 12g7le 6 �//✓ i r, 6� �. 8 8 9 9 zz 10 10 - - - - 11 O C Aol, '(f., 11 T® 12 /N� �'i9.�.>G� si 12 3,4AID CZAY ®�� z 13 cep T®AJC�X /S� 14 '14 77-44 15 15 16 16 SUITABLE FOR SUB-SURFACE SEWAGE: LEACHING FIELDvo'LEACHING PITS t/ LEACHING TRENCHES UNSUITABLE FOR SUB-SURFACE SEWAGE . REASONS: NOTE: ENGINEERING PLANS MUST SHOW NUMBER .ASSIGNED ON PERC TEST APPLICATION ORIGINAL: COMPLETED IN ENTIRETY BY P .-U . AND RETURNED TO BOARD OF HEALTH COPY: RETAINED BY APPLICANT yt-t+- ASSESSORS MAP: TEST HOLE 10GS i) installation shall comply with the State Environmental Code Title V and Town of r- -r - o - . Board of Health Regulations. PARCEL: SOIL EVALUATOR:__ M1 2) The septic system as proposed on this plan shall not be installed until a licensed-town L- installer receives approval and an installation permit from the applicable town. REFERENCE,� � Zo�� WITNESS: ) 1� � J "✓ 3) Prior to installation,the installer shall verify the location of utilities,sewer inverts, t- "�Lk &1/Ro V,) -pup" : sewer lines and existing septic components prior to installation. DATE 4) All gravity sewer piping is to be 4 inch schedule 40 PVC at 1/8"per foot. The first 2 PERCOLATION RATE: G C,J feet out of the distribution box shall be level. All piping connections to be glued. S) This septic design plan is not to be utilized for property line determination or for:any T.H.#1 ELEV. 9Y2e 0_ T.H.# ELEV,dr�5252, . otherpurpose other than the proposed septic system installation. LOCATION MAP 6) All Title v components are to meet Title v specifications. y l } 7) Parking shall be prohibited over Title V components unless components are H2O ` `1 loaded. N 8) The existing leaching or cesspools shall be pumped and filled with material per Title V 1AI � abandonment procedures. Leaching and cesspool(s)and contaminated soils within 1 the proposed SAS shall be removed and replaced with clean sand per Tide V specifications. t �* �� 9) Septic components are to be 10'from a water service line.Sewer lines crossing a water line shall be sleeved with an appropriately sized schedule 40 PVC with ends grouted. The water service line or the se in� 8ro septic line can be sleeved with the sleeve being a la a distance of 10'on both sides of crossing the line. 10)If a garbage grinder exists in the structure,it is to be removed if the septic system is �1• not designed to accommodate a garbage grinder. 11)The installer is responsible for care of excavation around all utilities on the property I - and protecting the structural Integrity of all structures during the installation process � � SEPTIC SYSTEM DESIGN CALCULATIONS i?>' �ti�ti01 of the septic system. lop FLOW ESTIMATE: 12)This plan only represents that a septic system can be installed on the property (O _.�-� meeting Title V requirements. BEDROOMS AT GAL/DAY/BDRM= L�.�C./ GAL/DAY SEPTIC TANK: 13)The property owner shall review design criteria to approve the total number of bedrooms and design flow. installation of the septic system as proposed and receipt . GAL/DAY/BDRM X 2 DAYS=t t-01D GALLONS of payment for the design shall be deemed approval of the design criteria by the . bb �...� �:} All property owner or agent of. 6� - USE GALLON SEPTIC TANK(F;-1C.� 1�(� 14)The valid' of this Ian shall expire ' - AY P p e with the expiration of the town installation permit (GARBAGE GRINDER IS PROHIBITED) issued for this plan or the valid' of this an shall expire on the �� _ •-; � �a;J�f P rtY plan p' expiration of the Certificate of Compliance issued for the installation of the proposed system on this SOIL ABSORPTION SYSTEM: , V44 6 �J plan. OF� r•�•:�� ' SIDEWALL AREA: �s f b� r BOTTOM AREA: S I Z 1 �j✓ bU � �'� 1; Pjo.1066 SEPTIC SYSTEM SECTION c#► 00 BENCHMARK 1 b ikt 6 r h�, s - � � �..-••"'-.r : �� _ +►J t�.1 s.l a q''�t TOP OF FOUNDATION 1l � ,iD� g'r� 62 FIL e ELEV. d7 eo, -4 IIW31 e► '' " "r' f 4q�. f'r�';fr f, ' -4� (DATUM ASSUMED) GiS 6"sTONEBASE �� 1 7 , •r�r ,fir r, ,f 7�,.At y W00-1 lot ,,e H2O D-BOX .* , �'� - `y �J,f'�,,��,,=;f�A: . '.�•f"� 6"STONE BASE OR COMPACTED BASE WATER TEST FOR LEVELNESS 0 1 4 1000 GALLONS SEPTIC TANK SITE AND SEWAGE PLAN I LOCATION. — - /� v4v_ _ � PREPARED: _ 'C' ►G SCALE: I „ — DATE: ZvC�? . I SYS M PROFILE.LEGEND TOP OF FNDN = 83.7' =s TEST HOLE LOGS u TRACKS NOT ALLOWED ACCESS COVER TO WITHIN 6' OF FIN. GRADE ajUT TO SCALE) RAILRW SEPTIC DESIGN (GARBAGE DISPOSER IS PROPOSED SPOT ELEVATION f:C 3S COVER (WATERTIGHT) TO ENGINEER: DANIEL A. OJALA, SE 100.0 �- DESIGN FLOW: 3 BEDROOMS ( 110 GPD) = 330 GPD MINIMUM .75, OF COVER OVER PRECAST /` �ITII"N 6' OF FIN. GRADE 100x0 EXISTING SPOT ELEVATION USE A 330 GPD DESIGN FLOW _ 2R SLOPE REQUIRED OVER SYSTEM 83.0 WITNESS: NONE 00 SEPTIC TANK: 330 GPD < ) = 660 S 1• t;4IN PIPE LEVEL 2' DOUBLE WASHED PEASTON - DATE: MARCH' 29, 2002 !• PROPOSED CONTOUR f',�,LR FIRST 2• 1000 EXIST. j000 .� 3' MAX, PERC. RATE _ < 6 MIN/INCH 100 EXISTING CONTOUR USE A ____ GALLON SEPTIC TANK (EXIST) 80 1 f GALLON SEPTIC ' LEA_ CHI�NC_ TANK (H- 10 > GAs H-2 1 H-20 80.0' CLASS I _ .SOILS P# - SIDES: 2(33.5 + 9.83) 2 (.68) = 117.8 RE-USE BAFFLE 79,44' «' -� -`'7 p p p p 0 m p CO O .01 BOTTOM: I :: 33.5 x 9.83 (.68) 223•g 6' CRUSHED STONE OR MECHANICAL Q 79.17' 0 p p p p p p p prZr , COMPACTION. t15.221 [27) � p p p p p p p [:3 ODES ELEV. ELEV. Focus TOTAL: 502 S.F. 341.7 GPD g 2 0 0 0 p p 00 M CJ , DEPTH OF FLOW = . _ (2 8 X SLOPE> ( !` SLOPE) USE 3 H-20 500 GAL. LEACHING CHAMBERS ACME OR TEE SIZES, „ 3/4' TO 1 1/2' DOUBLE WASHED STONE 0--= Q 83.0' �" Q 83.0' EQUAL) WITH 3.5' STONE AT ENDS AND 2.5' AT SIDES INLET DEPTH = 10 A SL OUTLET DEPTH = 14" 6" 1OYR 3/2'_ B LOCATION MAP NTS LEACHING B - FOUNDATION - EXIST. SEPTIC TANK 23' D BOX 12 FACILITY 7•17' LS LS 10YR 6/8 BOARD OF HEALTH ASSESSORS MAP 277 PARCEL 23 36" 80.0' 36" 80.0' MA APPROVED DATE NOTE PREVIOUS TEST HOLES P#7821 70.0' C PERC® C LS LS Oro SPA ��O• 00�0 2.5Y 6/:4 2.8 EXISTING WELL EXISTING WELL EAS£MEN T / 156" 70.0' 132" 71.0' �� NO 1VATER ENCOUNTERED v N TES, 1• DATUM IS APPROXIMATED FROM QUAD 2. DWELLING SUPPLIED BY WELL WATER rn 4 LOT 10 3. MINIMUM PIPE PITCH TO BE 1/8' PER FOOT. 4. DESIGN LOADING FOR ALL PRECAST UNITS TO BE AASHO H- 20 2.87f ACRES 124,958t FT. 5. PIPE JOINTS TO BE MADE WATERTIGHT. y` ��o J 646 6. CONSTRUCTION DETAILS TO BE IN ACCORDANCE WITH MASS. -� 6S ENVIRONMENTAL CODE TITLE V. 7. THIS PLAN IS FOR PROPOSED WORK ONLY AND NOT TO BE s ss + USED FOR LOT LINE STAKING. 4 9 \ / p 8. PIPE FOR SEPTIC SYSTEM TO SCH., 40-4' PVC. A� 9, COMPONENTS NOT TO BE $ACKFILLED DR CONCEALED WITHOUT + `�� 63.8 Y,:, INSPECTION BY BOARD OF HEALTH AND PERMISSION OBTAINED T _ 7 '3 .`` - __-- .� � ._ --.-- _. _ -�- ,��.. � ,� .,y rs r F�i�„` KUHRi�" C7r BENCH MARK - NAIL SET IN + 10. CONTRACTOR SHALL BE RESPONSIBLE FOR VERIFYING THE 14" PINE EL. = 86.0' 8 s LOCATION OF ALL UNDERGROUND & OVERHEAD UTILITIES PRIOR + 798 NOTE: SEVERE TOPOGRAPHY OVER TO COMMENCEMENT OF WORK. 8� e1•7 8nc_ g, +80' / ENTIRE LOT 11. PUMP AND REMOVE (OR FILL WITH CLEAN SAND) FAILED LEACH PIT 80.8 _ 8 - -- + 3 2.1 TITLE 5 SITE PLAN RE-USE EXIST. �- 1000 GAL. SEPTIC + 83.8 •2 8 trWELLING i TANK p OF 83. 83 L& 2.8 a5 PROP. VENT s 83.6 TH, TH 283 0 L D JAIL LANE j (FINAL IN THE TOWN OF: PLACEMENT BY 85-1 3' GARAGE CONTRACTOR WITH + 88 .3 (SLAB) BARNSTABLE ( VILLAGE) } HOMEOWNER) 8T .5\` i 8 86 --g6 PREPARED FOR: M/M BENJAMIN JONES a ` 94 9 Soo - 30 0 30 so 90 9 8F 92 9 ----�`9293 -- - 4 N r, - g � 9495 _,85 N APRIL , SCALE: 1 - 30 DATE: 2002 96-- 95 6 - 97- 97 1797.7 ' I VACANT �� Uf j VN OF ARNE ��s. �� ARNE H. 4G H. LA C V No.o.26348 792 / I 9 i A qc Hao A, 1AL I>ATE s. •Og, I J� 3. a ,off 508-362-4541 fox SGO 3E2-9m I r down cope end, eer hg, i►��c. q . CIVIL ENGINEERS LAND SURVEYORS 939 vain st. yarmouth, ma 02675 - 02--087 - Mo.. \ 9B.-moo TOP OF FOUNDATION CONCRETE COVER T CONCRETE COVERS 4"CAST IRON 2' 12"MAX OR SCHEDULE 4� 4"SCHEDULE 40 PVC.(ONLY) PVC. PIPE PIPE - MIN. LEACH PITCH I/4"PER. PITCH 1/4"PER.FT PIT e'. PRECAST � N V -� LEACHING o' ERT � a :.; •• EL.. ? INVERT INVERT , PIT OR a aJ �•• INVERSEPTToIC TANK y BOX 0 �. EL.. . '` 7Z EL.9�DIST %o 3 j= EQUIV. EL..�J197 EL.GAL. INVERT INVERT u Q :i: 3/4"TO IVY 9SZ E047oU. U. WASHED w .;• STONE ,� • /S / 7S/ �• EC.SB.•j. IL I u •, Y • . , i !Z, . DIA. a*/�«••/Tcr�v PROFILE OF �GROUND WATER TABLE ti SEWAGE DISPOSAL SYSTEM ' ,qc5;/ 7„e ze„Aoo, ' NO SCALE Aa?_&H Ar�O Io'B�ylA.�a 24�A"-D h/•rr/ C�6Y�)v SOI L LOG WITNESSED BY : h h DATE t 7� �S��/ TIME./o•oo!}!p 17nNNA /o,2/�ND/ BOARD OF HEALTH TEST HOLE I TEST HOLE 2 ENGINEER / ELEV. 97. 70 ELEV. l� VIM �RI w000[oA,� woueGo�r� `?4. 42 DESIGN DATA .' 9•f.7v � —E2. /02 /7 Lam' So"4r'yt•7o NUMBER OF BEDROOMS 3 L�/t�.:s of 7 . . . . . . 0011� �� MAD• TOTAL ESTIMATED FLOW J310. . . . GALLONS/DAY SAwAo _,�,�x, BOTTOM LEACHING AREA ��3• . SQ.FT. /PITlc/?D. S>aN&f SIDE LEACHING AREA 2Z'-1' Z- SQ.FT./ PIT SLS.S GARBAGE DISPOSAL ^�Oi�E (50% AREA INCREASE) 0 t+� fy�/c DtN=� � L �' TOTAL LEACHING AREA . s.�I. 3 SO.FT soN� s��^►�x`cgy a4 7� i��' .4Z G 7 PERCOLATION RATE Gass .n1a>. ?�'��. MIN/INCH of WATER ENCOUNTERED LEACHING AREA PER PERCOLATION RATE e74Y.1 SQ.F' L QovN' � NUMBER OF LEACHING PITS 0.vtl� "�-7", / hrG 77Aolc Fir o% -'iat c• �. '?�.... APPROVED BOARD OF HEALTH NT ,NSPECTOR / r 'r G•J 3 Z 1111�\,.v 7B 'I Y , ,>-- I ---- g Z r1, 13 96 T70n/K - D w�sc, _ _ 8 k��ct'vE • / U p ` ra 7�: 3 7 7