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Home My WebLink About0331 OLD JAIL LANE - Health 331 Old Jail Lane Barnstable - - A= 037—277 i I Commonwealth of Massachusetts Title 5 Official Ins' ection form o p Subsu i ace Sewage Disposal System Form-Not for Voluntary Assessments 331 Oldl Jail Lane Property Address Whitney P Wright Owner Owner's Name information is I required for Barnstable ' Ma. 02630 May 26,2011 every page. Cltylrown State Zip Code Date of Inspection 4 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. I Important: A. General Information When filling out I forms the computer, r,use 1. Insp,ctOr: I only the tab key to move your Allan C Taylor use the return urn cursor- not Name of Inspector key. Canal Land Surveying @ Permitting �I Company Name t14306 Old Plymouth Rd. Company Address Sagamore Beach Ma. . 02562 'dBJ C' ' State frown � i - :Zip Code 508-888-5955 S12487 m f Telephone Number License Number a ' B. Certification f - o I certify that I have personally inspected the sewage disposal system at this address and that theme information reported below is true, accurate and complete as of the time of the inspection.:me 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 16.340 of Title 5(310 CMR 15.000).The system: i ® Passes ❑ Conditionally Passes ❑ Fails, ❑ Needs Further Evaluation by the Local Approving Authority C!1 6/3/2011 Inspector's Signature Date The system inspector shall s bmit 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 deport 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. f a � J t5ins•11l10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 I l Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 331 Old Jail Lane Property Address Whitney P Wright Owner Owner's Name information I requ ed forts Barnstable Ma. 02630 May 26,2011 every page. City/Town { State Zip Code Date of Inspection B. Ceriffication (cunt.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: ; All co T ponants were opened and inspected and found to be in the same condition as the inspection datedi 10/27/2011 found in town records. The dwelling has not been occupied for the last six months. affluent levels reflect no use,with stain lines on leaching pits as recorded in 10/27/2011 f I O e or mores stem components as described "Ely p in the Conditional Pass section need to replaced or repaired. The system, upon completion of the replacement or repair, as proved by the Board of Health, will pass. Check!the box for"yes", "no" or"not determined" (Y, N, ND)for the following ements. If"not determined," please explain. The septic tank is metal and over 20 years old"or the septic tank ether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltrati or tank failure is imminent. System will pass inspection if the existing tank is replaced with a c plying septic tank as approved by the Board iof Health. "A metal septic tank will pass inspection if it i r turally sound, not leaking and if a Certificate of Compliance indicating that the tank is less an 20 years old is available. ❑ Y , ❑ N ❑ Explain below): i t5ms•11/10 Title 5 Official Inspection Foam:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments '< 331 Old Jail Lane Property Address Whitney P Wright Owner Owner's Name information is Barnstable required for Ma. 02630 May 26,2011 every page. Cityfrown State Zip Code Date of Inspection B. Certification (Cont.) nt ❑ 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. Syste ill pass inspection if(with approval of Board of Health): El broken pipe(s)`are.replaced ❑ Y ❑ N ❑ ND(Explain belo ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain elow): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Ex in be ❑ The system required pumping more than 4 times a year ue"to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Bo d of Health): broken pipe(s)are replaced Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): C) /aaaluation is equired by the Board of Health: ❑ exist wh' h re uire further evaluation b the Board f q y oa d o Health in order to determine if is faili g to protect public health, safety or the environment. w' pass unless Board of Health determines in accordance with 310 CMR that the system is not functioning in a manner which will protect public health, the environment: sspool or privy is within 50 feet of a surface water t5ins•11/10 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System!Page 3 of 17 Commonwealth of Massachusetts Title; 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 'f 331 Old Jail Lane Property Address Whitney PIWright Owner Owner's Name information is Barnstable Ma. w 02630 May 26 2011 required for y , every page. Cityrrown state Zip Code Date of Inspection B. Certification (cont.) determines that the system is functioning in a manner that protects the public he , safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and th AS 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 e 1 of a public water supply. ❑1 'The system has a septic tank and SAS and the SAS is wi n 50 feet of a private water supply well. ❑ Th'e system has a septic tank and SAS and the SAS is les an 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** his system passes if the well waterZanaeed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that noeria are triggered.A copy of the analysis,must be attached to this forma 3. Other. D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ® Backup of sewage into facility or system component,due to overloaded or clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters ® due to an overloaded or clogged SAS or cesspool ❑, ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool �( ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 i Commonwealth of Massachusetts Title' 5 Official -Insp ection Form Subsurface Sewage Disposal System Form-Not for Vo luntary oluntary Assessments ' 331 Old Jail Lane Property Address Whitney P Wright Owner Owner's Name information is garnstable� required for Ma. 02630 May 26,2011 every page. Cityrrown I 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: ❑I ® Any portion of the SAS, cesspool or privy is below high ground water elevation. 0 Z Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ Z Any portion of a cesspool or privy is within a Zone 1 of a public'well. ❑I ER Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑I E Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal 9 to or less than 5 m 9 q pp provided that n p o other failure criteria are triggered.A copy of the analysis and chain of custodymust be attached to this form.] ] The system is a cesspool serving a facility with a design flow of 2000gpd- ❑ 10,000gpd. ❑ 0 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. —.V- y8te -s. To b"o side ad a ai go system tole systell.Must se.9.Fe a facilitly —%93 design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the followin addition to the questions in Section D. Yes No El ❑ the system is within 400 feet of a ace drinking water supply ❑ ❑ the system is within 2 eet of a tributary to a surface drinking water supply ❑ El the system is ated in a nitrogen sensitive area (Interim Wellhead Protection Area-I )or a mapped Zone II of a public water supply well If you have answere es"to any question in Section E the system is considered a significant threat, or answered"y " n Section D above the large system has failed. The owner or operator of any large system co ' ered a significant threat under Section E or failed under Section D shall upgrade the syste n accordance with 310 CMR 15.304. The system owner should contact the appropriate t5ins•11/10 Tice 5 Official Insp ection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Y331 Old Jail Lane Property Address Whitney P Wright Owner Owner's Name information is Barnstable required for Ma. 02630 May 26,2011 every page. Cityrrown State Zip Code Date of Inspection C. Checklist Check�if the f 11 " 0 owing have been done. You must indicate yes or"no"as to each of the following:. Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in,the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has. been determined based on: 0 ❑ 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)] f 1 D. System Information Residential Flow Conditions: Number of bedrooms(design): - 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 t5ins-11110 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 331 Old Jail Lane Property Add ess Whitney P Wright Owner Owners Name information is required for Barnstable Ma. 02630 May 26,2011 every page. Citylrown State Zip Code Date of Inspection D. System Information Description: Number of current residents:. 0 Does residence have a garbage.grinder? ❑ Yes.® No Is laun ry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ElYes ® No Water meter readings, if available last 2 ears usa a WELL 9 ( Y 9 (gPd))� Detail: i I Sump pump? ❑, Yes ® No Last date of occupancy: JDaa�. 2011 { 4 Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons day(gpd) Basis o�f design flow(seats/persons/sq.ft., etc.): f Grease trap present? El Yes ❑ No Jndustrial waste holding tan sent? ❑ Yes ❑ No Non-sanitary a discharged to the Title 5 system? ❑ Yes ❑ No i t5ins,'11/10 Title 5 Official Inspection Foam:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal.System Form-Not for Voluntary Assessments '< 331 Old Jail Lane Property Address Whitney P Wright Owner Owner's Name information is Barnstable required for Ma. 02630 May 26,2011 every page. Citylrown • State Zip Code Date of Inspection D. System Information(cont.) . Date .Other(describe below): General Information Pumping Records: Source of information: Pumped right after 10/27/2008 inspection Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: routine 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) El Innovative/Altemative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•1 V10 Title 5 Official Insp ection Form:Subsurface Sewage Disposal System•Page 8 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection, Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 331 Old Jail Lane Property Address Whitney P Wright Owner Owner's Name information is Barnstable required for Ma. 02630 May 26,2011 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) y Approximate age of all components, date installed (if known)and source of information: 12/92 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: " 2' .feet Material of construction`. ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: 90'+ feet Comments(on condition of joints, venting,evidence of leakage,-etc.): venting and joints visable are all in ggood condition, building sewer exits structure under floor slab Septic Tank(locate on site plan): Depth below grade:. 24'2-1.0' risers/inlet cover down 4" feet Material of construction: concrete ® ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) ) Outlet cover 2' below grade If tank is metal, list age: years Is age confirmed by.a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No . Dimensions: 10'6"x5'8"x5'8" Sludge depth: 1 t5ins•i ino Title 5 Official in spection Forth:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form . Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM <a 331 Old Jail Lane Property Address Whitney P Wright Owner Owner's Name information is Barnstable Ma. 02630 May 26,2011 required for Y every page. Cityrrown I State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 24" Scum,thickness Distance from top of scum to top of outlet tee or baffle 51/2 Distance from bottom of scum to bottom of outlet tee or baffle 23 How were dimensions determined? measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): recommend pumping every two years of normal use,- Depth below grade: feet Material of construction: I ❑ concrete El metal ❑ fiberglass ❑ ethylene ❑ other(explain): j I Dimensions: � R Scum thickness Distance from top of m to top of outlet tee or baffle Distan k bottom of scum to bottom of outlet tee or baffle Date t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments < 331 OId Jail Lane{ Property Address Whitney P Wright . Owner Owner's Name information is I "y required for Barnstable <e Ma. 02630, May 26,2011 every page. City/Town _ a. State Zip Code' Date of Inspection D. System Information (cont.) keR pumping FeeemmendatieFie, inlet and outlet tee ep baffle e6iciditien, sitpulet��a Mte--: liquid levels as related to outlet invert, evidence of leakage,etc.): Tight or Holding Tank(tank must be pumped at time of inspection)'(Ioca on site plan): Depth below grade: w Material.of construction: , concrete ❑ metal ❑fiberglass ❑ polyethylene ❑;other(explain): Dimensions: Capacity; gallons x "Design Flow; gallons per day - • El a Alarm present:-' Yes: No Alarm level; . Alarm in working order:- `, ❑-Yes [],No Date of la/(con9f pate , Comment and float switches, etc.): d t5ins•11/10 Title 5 official Inspection form:Subsurface Sewage Disposal System•Page 11 of 17 . . I Commonwealth of Massachusetts Title 5 Official Inspection form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments y 331 Old Jail Lane Property Address Whitney P Wright Owner Owner's Name information is Barnstable required for Ma. 02630 May 26,2011 every page. Cityrrown 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 0 Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box,,etc.): No evidence of leakage or solids carryover,box was level,cover was broken in previous inspection and replaced with a 2".thick flat slate stone; Pumps in working order: ❑ Yes o Alarms in working order: ❑ Ye ❑ No Comments(note condition of pump chamber, condition of pumps and a �rtenances, etc.): / Soil Absorption System (SAS) (lo a on site plan, excavation not required): If SAS not located, explain w t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 331 Old Jail Lane Property Address Whitney P Wright Owner Owner's Name information is required for Barnstable Ma. 02630 _ May 26,2011 every page. City/Town State i Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 2 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields . number, dimensions: ❑ overflow cesspool number: ❑ innovative/altemative system Type/name of technology: Comments(note condition'of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): no signs of hydraulic failure,both pits#4 has sand showing in bottom and#3 has,.50'of.affluent; grease line in pit#3 at 3.5'down from top,and pit#4 is 5 5'down from top; Geespeels(eesspeol rntist be purnped as part of ispeetion) (locate on site plat 1)0 Number and configuration Depth-top of liquid to inlet invert Depth of solids layer tv Depth of scum layer Dimensions of cesspool- Materials of c ction 6 .. _sins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 f _ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary_Assessments 331 Old Jail Lane Property Address Whitney P Wright Owner Owner's Name information is Barnstable required for Ma. 02630 May 26,2011 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) etc.): • PrivY(I ocate on site plan): Materials of construction: Dimensions Depth of solid's Comments(note condition of so', signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•11/10 f Title 5 Official Inspection Forth:Subsurface� Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts' Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments w ' 331 Old Jail Lane . Property Address, , Whitney P Wright Owner Owner's Name information is required for Barnstable Ma. 02630 May 26,2011 • ' every page. Cityfrown State Zip Code. -Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, in ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ❑ drawing attached separately-, . , well FRONT HOUSE °c AND .GARAGE x° :NOT TO SCALE: X C hro^ •A B ' 1500 cAL. ' CONCRETE' sePnc/IN ooVMETAINING WALL LEACHINGVER PIT#3 o-eox LEACHING QZ PIT#4 A-1=36.4' B-1=52.4' A-1A=41.4' , A-2=56.7' _ B-2=7.4.7' A-3=52.0' 6-3=82`5' A— C-4=80.5' t5ins•11/10 Title 5 Official Inspection Form:,Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments •' 331 Old Jail Lane Property Address Whitney P Wright Owner Owner's Name information is Barnstable required for Ma. 02630 May 26,2011 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ' ❑ Shallow wells Estimated depth to high ground water: 14'Plus feet 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: 1/2/1992 Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain:, ma. GIS compared elevations of surrounding ponds etc You must describe how you established the high ground water elevation: reviewed existing site plan dated 1/2/1992 and observed elevations of surrounding properties; Before filing this Inspection Report,please see Report Completeness Checklist on next page. t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form t Subsurface Sewage Disposal System Form.-Not for Voluntary Assessments �< 331 Old Jail Lane. Property Address Whitney P Wright-,' x' Owner Owner's Name information is Barnstable a Ma; 02630 May 26 2011 required for y , every page. CityrFown State Zip Code Date of Inspection E. Report Completeness Checklist ® 'Inspection Summary:A B, Q,D or checke d r ® .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 w. c • t5ins•11/10 y Tifle 5 Official Inspection Forme Subsurface Sewage Disposal System-Page 17 of 17 r s Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments '< 331 Old Jail Lane Property Address Whitney P.Wright Owner Owner's Name information is required for Barnstable Ma. 02630 10/27/2008 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important.- A. General Information When filling out forms on the � A computer,use 1. Inspector: only the tab key to move your Allan C.Taylor cursor-do not use the return Name of Inspector key. Canal Land Surveying& Permitting Company Name 18 Route 6A Company Address Sandwich Ma. 02563 _ I lraw I I� City/Town State Zip Code 508-888-5595 S12487 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Titles(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ 'Fails Y'= '31 ❑ Needs Further Evaluation by the Local Approving Authority , N) 11/06/2008 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins-09/08 Title 5 Official Inspection Form:Subsurface Swage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Titles Official Inspection Form Subsurface Sewage Disposal System Foam -Not for Voluntary Assessments j 331 Old Jail Lane Property Address Whitney P.;Wright Owner Owner's Name information is required for Barnstable, Ma. 02630 10/27/2008 every page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D l 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 eanditionally Passes! I '❑ One or more system components as described in the "Conditional Pass"section nee be replaced or repaired.The system, upon completion of the replacement or repair, approved by the Board of Health,will pass. I Checkjthe box for"yes", "no"or"not determined" (Y, N, ND)forthe followin atements. If"not determined,"please explain. The septic tank is metal and over 20 years old*or the septic tan hether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltr . n or tank failure is imminent. System will pass inspection if the existing tank is replaced with mplying septic tank as approved by the Board'of Health. *A metal septic tank will pass inspection if it' st cturally sound, not leaking and if a Certificate of Compliance indicating that the tank is le an 20 years old is available. ❑ Y ❑ N ❑ (Explain below): i t5ins•09/08 i Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 331 Old Jail Lane G s Property Address Whitney P.Wright Owner Owner's Name information is required for Barnstable Ma. 02630 10/27/2008 every page. City/Town State Zip Code • Date of Inspection B. Certification (cont.) ❑ Observation of sewage backup or breakout or high static.water level in the distribution box e to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. Sys m will pass inspection if(with approval of Board of Health): El broken,pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain b ow): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Expl ' below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND ( plain below): ❑ The system required pumping more than 4 times a ye due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the and of Health): El broken pipe(s) are replaced Y. ❑ N ❑ ND'(Explain below): ❑ obstruction is removed ❑, Y ❑ N ❑ ND (Explain below): , C) .Further Evaluation i equired by the Board of Health: ` a ❑ Conditions exist w h require further evaluation by the Board of Health in order to determine if the system is fail' g to protect public health,safety or the environment. 1. System w" pass unless Board of Health determines in accordance with 310 CMR 15.303(1)( that the system is not functioning in a manner which will protect public health, safety a the environment: ❑ Cesspool or privy is within 50 feet of a surface water peal or privy within 50 feet of a bvide,ing vegetated wetland h t t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments y 331 Old Jail Lane Property Address Whitney P.Wright Owner Owner's Name information is Barnstable Ma. 02630 .10/27/2008 required for every page. Cityfrown State Zip Code Date of Inspection B. Certification (cont) 2. System will fail unless the Board of Munit Mtot Supplier,if 2"y) determines that the system is functioning in a manner that protects the public hea , safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the S 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 Z e 1 of a public water supply. ❑ The system has a septic tank and SAS and XSASis50 feet of a private water supply well. ❑ The system has a septictank'and SAS and the SASfeet but 50,feet or more from a private water supply well*"°. Method used to determine distance: *"This system passes if the well water analysi , performed at a DEP certified laboratory,for coliform bacteria indicates absent and the presence ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other (lure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other. Dj System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No 0 ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters ❑ ® due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6"below invert or available volume is less . than%day flow dins•09108 Title 5 Official Ins pection Form:Subsurface Sege Disposal Systerm•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 331 Old Jail Lane Property Address V Whitney P.Wright Owner Owner's Name information is Barnstable required for Ma. 02630 10/27/2008 every page. City/Town State Zip Code Date of Inspection B. Certification (c nt.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. r , ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] 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 c i. riteria 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) 6aFge —P-be eene'de--d a large.system the system must serve a feeility"WiNh design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the follow' , in addition to the questions in Section D. } Yes No I ❑ ❑ the' system is within 400 feet of rface drinking water supply ❑ ❑ the system is within eet of a tributary to a surface drinking water supply ❑ the system i ted in a nitrogen sensitive area (Interim Wellhead Protection' . Area—I A)or a mapped Zone II of a public water supply well if you have answe sn to any question in Section E the system is considered a significant threat, or answered"ye " n Section D above the large system has failed.The owner or operator of any large System co ered a significant threat under Section E or failed under Section D shall upgrade the syste ' accordance with 310 CMR 15.304.The system owner should contact the appropriate raftment. t5ire•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 s L Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments `~ 331 Old Jail Lane Property Address Whitney P.Wright Owner Owner's Name information is Barnstable required for Ma. 02630 10/27/2008 every page. Cityrrown l 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 ❑ ® I ere 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) ® ❑ �as 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 bee n determined based on: ® ❑ E sting 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)] l D. System Information I Residential Flow Conditions: Number of bedrooms(design): 4 Number of bedrooms(actual): 4 M4 � DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 i I t5ins•09M I Title 5 OfficW Ins J pection Form:Subsurface Sswage Disposal System•Page 6 of 17 i ,. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 331 Old Jail Lane Property Address Whitney P.Wright Owner Owner's Name required on is Barnstable required for I Ma. 02630 10/27/2008 every page. City/Town State Zip Code Date of Inspection D. System Information Description: I i f . Number of current residents: 2 Does residence have l garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? El Yes ® No Seasonal use? I ❑ Yes ® No Water meter readingsjif available (last 2 years usage (gpd)): Detail: l well water { , Sump pump? ❑ Yes ® No Last date of occupancy: current Date Type of Establishment:'I . Design flow(based on 310 CMR 15.203): capons y(gpd) r Basis of design flow,(sea is/persons/sq.ft., etc.)- Grease trap present? ❑ Yes ❑ No Industrial waste holding�tank ent? ❑ Yes ❑ No Non-sanitary w ischarged to the Title 5 system? ❑ Yes ❑ No . t5ins•09= Title 5 Official insp ection Form:Subsurface Sewage Disposal SysOem•Page 7 of 17 I ' Commonwealth of Massachusetts • Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 331 Old Jail Lane Property Address Whitney P.Wright Owner Owner's Name information is Barnstable Ma. 02630 10/27/2008 required for � ' every page. Cityrrown State Zip Code Date of Inspection D. System Information (cunt.) Last date of occupancy/use: Da cute Other(describe below): 'f f k General Information i Pumping Records: Source of information'. Was system pumped 'as part of the inspection? ❑ Yes ® No If yes,volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single�cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no (if yes, attach previous inspection records, if any) f. ❑ Innovative/Alternativetechnology.Attach a copy of the current operation and maintenance contrail(to be obtained from system owner) and a copy of latest inspect n of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 r I I Commonwealth of,Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments I yt 331 Old Jail Lane Property Address Whitney P.Wright Owner Owner's Name information is required for Barnstable Ma. 02630 10/27/2008 k every page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components,date installed (if known)and source of information: 12/92 { 1 Were sewage odors detected when arriving at the site? ❑ Yes ® No i Building Sewer(locate on site plan): i De 2� - h below Pt grade: feet .f Material of construction: i I ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private iwater supply well or suction line: feet I , Comments(on condition of joints,venting, evidence of leakage, etc.): I k Septic Tank(locate on site plan): Depth below grade: j 2'-4"2-1.0' risers,cover down 4" � feet Material of construction: r ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: yearn Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 10'6"x5'8"x5'8" Sludge depth: 1.5" t t5ins•09l08 Title 5 Official)ns_I pectlon Forth:Subsurface Sewage Disposal System•Page 9 of 17 I 6 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System form -Not for Voluntary Assessments 331 Old Jail Lane j Property Address Whitney P.Wright G Owner Owner's Name I information is gamstable required for Ma. 02630 10/27/2008 every page. Cityfrown I State Zip Code Date of Inspection D. System Information (cunt.) Septic Tank(cunt.) Distance from top of sludge to bottom of outlet tee or baffle 38.5" Scum thickness 1.011 r Distance from top of scum to top of outlet tee or baffle 5" Distance from bottom I!of scum to bottom of outlet tee or baffle 19" How were dimensions determined? Measured 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 evidence of leakage,tank has good structual integrity. I j I I I k Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass yeth lene II y Yt E] other(explain): - Dimensions: Scum thickness Distance from top of s I to top of outlet tee or baffle Distance fr om of scum to bottom of outlet tee or baffle I� ae t5ins•09/08 Title 5 Official Ins it pecUon Form:Subsurface Sewage Disposal System•Page 10 of 17 Ii I it Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments * 331 Old Jail Lane Property Address Whitney P.Wright Owner Owner's Name information is required for Barnstable Ma. 02630 10/27/2008 f every page. Cityrrown State Zip Code Date of Inspection D. System Information (cunt.) liquid levels as related to outlet invert,evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (loca on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order. ❑ Yes ❑ No Date of last pumping: Date Comments(conditi of alarm and float switches, etc.): ' Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 15ins•09f08 Title 5 Official ins pection Forth:Subsurface Sewage Disposal system•Page 11 of 17 P f r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 331 Old Jail Lane Property Address Whitney P.Wright Owner Owner's Game information is required for Barnstable Ma. 02630 10/27/2008 every page. CityfTown State Zip Code Date of Inspection D. System Information (coat.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): No evidence of leakage or solids carryover,box was level,cover was broken in excavation,and replaced with a flat stone cover. Pump eitanift, (locate on site plan). Pumps in working order: ❑ Yes ❑ No Alarms in working order. [Ell Yes No Comments(note condition of pump chamber, condition of pumps and appu ances, etc.): ZZ Soil Absorption System(SAS) (loca n site plan, excavation not required): If SAS not located, explain wh t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Rage 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Forms Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 331 Old Jail Lane Property Address Whitney P.Wright Owner Owners Name information is required for Barnstable Ma. 02630 10/27/2008 every page. City/Town state Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number 2 ❑ leaching chambers number: ❑ leaching galleries number. ❑ leaching trenches number, length: ❑ leaching fields number,dimensions: ❑ overflow cesspool number. ❑ innovative/aftemative system Type/name of technology: — Comments(note condition of soil, signs of hydraulic failure, level of ponding,damp soil, condition of vegetation, etc.): Both leaching pits are located in maintained lawn areas,no ponding or damp soil conditions,pit#3 has 3.6'to liquid level,with no grease line above. pit#4 has5.6"to liquid with no grease line above. Geespeels(eesepeel must be pumped as part of inspection) (locate on bite p1311). Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of co ction Ind' NAP Af Rfe t5ins-09108 Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Forth -Not for Voluntary Assessments 331 Old Jail Lane Property Address Whitney P.Wright Owner Owner's Name information is required for Barnstable Ma. 02630 10/27/2008 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) f- , etc.): Privy(locate on site plan): >7Z Materials of construction: Dimensions Depth of solids Comments(note condition of , signs of hydraulic failure, level of ponding, condition of vegetation, etc.): y t5ins•09/08 Title 5 Official Inspecdon Form:Subsurface Sewage Disposal System•page 14 of 17 I f Commonwealth of Massachusetts v Title 5 Official Inspection Form Subsurface.Sewage Disposal System Form-Not for Voluntary Assessments y` 331 Old Jail Lane Property Address Whitney P.Wright Owner Owner's Name information is required for Barnstable Ma. 02630 10/27/2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cunt.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system,including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ❑ drawing attached separately 9 C o nr GR�g' • 2Fi/�IN{NG yir-L s d,� IT`A nt K JJ) �1 % Clocp B- 1 A,— w a f t5ins•09MB Title 5 Official Inspection Forth:Subsurface Swage Disposal System•Page 15 of 17' r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments s 331 Old Jail Lane Property Address Whitney P.Wright Owner Owner's Name information is required for Barnstable Ma. 02630 10/27/2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ❑ Surface water ❑ Check cellar , ❑ Shallow wells Estimated depth to high ground water: 14'-j- feet 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: 1/2/1992 Date ❑ Observed site (abutting property/ ) ❑ 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: Reviewed existing site plan dated 1/2/1992 R . Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 n q ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 331 Old Jail Lane Property Address Whitney P.Wright Owner Owner's Name information is required for Bamstable Ma. • 02630 10/27/2008 every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® inspection Summary:A, B, C, D, or E checked ® inspection Summary D(System Failure Criteria Applicable to All Systems)completed E ® System Information-Estimated depth.to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-09M Trtle 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17, AsBuilt Page 1 of 1 e, 3� TOWN OF BARNSTABLE 'Q LOCATION l r (�- i ,. SEWAGE #_ VILLAGE f�3 sal- ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. i?,Y� l/J T'/llxdl'� th��/�� SEPTIC TANK CAPACITY LEACHING FACILITY:(type) 1 � Pj�sarr s , NO. OF BEDROOMS 3 PRIVATE WELL OR A BUILDER OR OWNER �.�� DATE PERMIT ISSUED: - DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No rem a men http://issgl2/intranet/Propdata/prebuilt.aspx?mappar=277037&seq=1 2/14/2014 i 'TOWN OF Bif R..STABLE L:bCATI..#-3w 0i ` �8 , � SEWAGE #_ VILLAGE ; . ASSESSOR'S .MAP & LOT 77(T 37 INSTALLER'S NAME& PHONE jl O. SEPTIC TANK CAPACITY LEACHING FACILITY:(tgpe) /000A �eA4 (ia NO. OF BEDROOMS 3 PRIVATE WELL OR BUILDER OR OWNER k f °.� DATE PERMIT ISSUED: z- DATE, COMPLIANCE ISSUED; 3 VARIANCE GRANTED: Yes No L/ i I-S !�YY 037 t. f Fizz....f.c9a....... THE COMMONWEALTH OF MASSACHUSETTS P '7V7 BOARD OF HEALTH It J ,k TOWN OF BARNSTABLE ;jVftratiou for Big os ai Works Toustrurtion ramit A lication is hereby made for a Permit to Construct (Lj or Repair ( ) an Individual Sewage Disposal PP Y P System at: OGD T/fr4 /2N ......................... � �3 Location-Address �[� or Lot No. ----...... .._... W �.eT1r 1 f3_ _!--`I1.C.ress -.. a l Installer Address �� - ..S feet � Type of Building Size Lot_.__._y._.._.�_...__ q. Dwelling—No. of Bedrooms............4---------------•--________-Expansion Attic ( ) Garbage Grinder ( ) '4 Other—Type T e of Building ............. No. of ersons..........................._ Showers — Cafeteria f-� YP g --------------- P ( ) ( ) p' Other fixtures ............................ W Design Flow.............. ......................gallons per person per day. Total dailyflow__._......'��._........_.._.._----gallons. WSeptic Tank—Liquid capacity�3 ...gallons Length/�.�_`�__ Width 4.� ..... Diameter---------------- Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No........L........ Diameter-_____ Depth below inlet......A.......... Total leachingarea.SL?A_.sq. ft. Z Other Distribution box ( ) Dosing tank ( ) a Percolation Test Results Performed by....4-12W ..... ............ Date.. "l -.- � � --------------- a Test Pit No. 1..Z_?_....minutes per inch Depth of Test Pit---- Depth to ground water....:r--!n.............. Test Pit No. 2--.� -...minutes per inch Depth of Test Pit--- Depth to ground water........................ a --------•-------------------------•--•-•----•------••--•---------•--------------.................---........................................................ 0 Description of Soil------ ....... oy 0461......V-f o�c ------------- =/3Z-'-_�-1 i../ . V -----WITH s ''`iE�S..................Z"=_!Lb'.....MAD.. S'......-....------------- . ---------------------- W •---------------------------•-----•------••-----•-••----------•-•----•--•-•-------------- •----•-----------------•-----------------•--•-•-•--••-•--••------••----•-•--------•---------------.._.......-- UNature 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 Wde—The under ' rther agrees not to place the system in operation until a Certificate of Complia een issued t e Nth. l Signed-- ------ --- ----- 4 ----------- ---------------------------------------- Date Application Approved By ................. ----- � .---- ---- ------------------. ---------- ...... . ----------------- --- Date Application Disapproved for the following reasons- -----------------------------------...--------...---........................................-------------------------------------- ---------- --------------------------------------------------------------- ------------------------------------------------------------------------ ----------------------- -----..................... ------------------------------------- Date PermitNo. ........ ............................... Issued --:-...---...........----- ----..........----...---------....------ Date i> . No...../.I:.1.Z& 1 Fi&s. .. ( . .....S... THE COMMONWEALTH OF MASSACHUSETTS P 7727 r �� BOARD OF HEALTH /1� ,, '�( � TOWN OF BARNSTABLE firaftva for UWpaiial Works Tonstrnrtiun ramit Application is hereby made for a Permit to Construct (4"')" or Repair ( ) an Individual Sewage Disposal System at: ' OGD T.9;,` Gl�r-� BAIZNST.�/3L� L�7 �/ �xhg%1OG N ass ��M Sor Lot dTo:4 SS' -• _........................'........ .................._......._._..._.............. -----........---............................_..... ddres. .. ................... Installer Address _ Type of Building Size Lot...l `_Y1......Sq. feet a Dwelling T eoof Building Expansion Attic ( ) Garbage Grinder ( ) p.l —Type g ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Q' Other fix_ eS - W Design Flow---/____________________________��.gallons per person vy day. Total 3ll Pow............................................ WSeptic-Tank—Liquid capacity............gallons. Length................ Width................ Diameter................ Depth...s.6 x Disposal Trench—No..................... Width Total Total Length................_._ Total leaching area.................... ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area_..`�L `g_sq. ft. Z Percolation Test Results ) Performed tank ( ) Other Distribution box d by....- ?yAr?�- --='---l��zG E�1�• ...... Date..�w� - ,3 _. a Test Pit No. 1--- ._�-_---minutes per inch Depth of Test Pit.----!�G.......... Depth to ground water...... .............. G Z per inch Depth of Test Pit___e'4 _. Depth to ground water........................ iT ODescriptionO .. . tes� ............................................ t=, Test at o. 0o i7Ga/�r"r SyJ v�-Solt _5Z ;", Str:3-01�o> � ...----•-. ---••------------------- --- 1 x ° �`? r ..-s=....`-'fl---------------•--------------------...........---....--- V .••• --------------------------•----------•-------•------------•--•---••-•--•---............_..--•-----------------------------.......------......••-••••-•-••.............--••-----•----------....... U Nature of Repairs or Alterations—Answer when applicable............................................................................................... .......... ... ... • ••. .. . ......--•••-••••-•••-•--•--•-.....-••••-•--•-•...........---•-----•---•----...---.:........ ......•-•---.....---•-•--••-••-•-••--..........•-- Agreement: _P The undersigned agrees to install the aforedescribed Individual Sewage Disp sal System in accordance with the provisions of TITLE 5 of the State Environmental e—The unders neA further agrees not to place the system in-operation until a Certificate of Compliant 1 "been issued b �tbe •oa' of h Ith. Signed ........... - -------------- Date Application Approved BY - � � -9z Sf� Dare ---- I Application Disapproved for the fo owing easonr- -------------------------------------------------------------------------------------------- ------- ........................ ---------------------------------------------------------------------------------------------------------------------------------------------------------- --------------------------------------------- .,��.:-. p Date PermitNo. ---------'/J---J 76--------------------------- Issued --------------------..-oa.e..........------------------------- q THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE &r#tftctt#P Hof C ontylinuce rtHn ivid 41 S agq°Disposal System constructed ( �or Repaired ( ) by STE FYThat th I r'e �=I/ .. Installer (I/J at ................... ....f' ..... vL `°C has been installed in accordance with the��Aisions of TITLE 5 of The State Environmental-Code as described in the application for Disposal Works Construction Permit No. ................................................ dated ................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.............Y. .- _ ................ ............... Inspector ............... 1��............................................................ THE COMMONWEALTH OF MASSACHUSETTS 01 BOARD OF HEALTH -- �' TOWN OF BARNSTABLE No...... ...�.1 4- TO FEE......�,/S.G)..... ,-' Disposal nrkg n15tr ' n �-ruti Permission is hereby granted = _..�'_.r. �1._.. .. ................•-•........: . Y g 0 �,, �� to Construct (✓) or Repair ( ) an Inylividual Sem age Disposal System atNo.......... >/ �J t e� .. ......9�............... .................................................... Street as shown on the application for Disposal Works Construction Permit No.�2L1,,7e_- Dated.......................................... V e •-------- Board of Health DATE... -5------1.-.-�:�.............. FORM 36508 HOBBS&WARREN.INC..PUBLISHERS 1 No.----------I-a=3 Fee---1S---------- BOARD OF HEALTH TOWN OF BARNSTABLE ZippYicat ion i orIVefr Cootructiotupermit Apqlica ion is herebypade for a permit to Construct ( ), Alter ( ), or Repair ( )an individual Well at: �Gc! Location — Address Assessors Ma P and Parcel �` 7� ------------------ /Owner r Address ZDe Installer — Driller Address Type of Building DwellingL� 2vv Other - Type of Building------------------------------------ No. of Persons---------------------------------------------------------- Type of Well ---------------------------------- Capacity Purpose of Well----- 6---- ----------------------- 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 u ' a Certi icate C m i ce has been issued by the Board of Health. Signed-------------- --------- ------------ --------------------------- date ApplicationApproved By------------------------------------------------------------------------------- -—__ -- ---------------- date Application Disapproved for the following reasons:--------------------------------------------------------------------—-------------------------------- -------------------------------------------------------------------------------------------------------------------------------- �y date PermitNo. —— -f O� - - -- ----- - Issued---------------------------------------------------------------------------------------- date BOARD OF HEALTH TOWN[ OF BARNSTABLE Certifirate ®f Compliance THIS IS TO CERTIFY, That the Individual Well Constructed, Altered ( ), or Repaired ( ) - --- ----------------- — - -- - bY--- -------------------------------------------------------------------------------- Installer C at-------- a ! -�� - ------- - has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation as described,in the application for Well Construction Permit No. -+'Y-�� = -----Dated---------------------------- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE------------------------------------------------------------------------------------- Inspector— - ----------- ------------------------------ �" _ > .. � -'^4 '�iyil"i.�'w+'..�'...�,.�'3`°c'�,i...r'�:.._-.ri_..a;.t�. ..�� ^��.y+.'�.v j- .J^+^ �'J�A�'✓`�-'a_.�• .,k'y,;.s..'fr'','ti �.i� a . . •' we 7 5\!// � f�� -4 --- q _ Fee- BOARD OF HEALTH TOWN OF BARNSTABLE �ylr 9ppricationArlperr CougtructionPermit '+( Application is hereby made for a,permit to Construct .( ), Alter ( ), or. Repair,( )an individual Well at: Location — Address Assessors Map and Parcel - ---------------------------- rSC _X'ef _ 'f G'- f(� • r��-s -- J Owner �`{ A�Addre s, _U,0?'? t 4 �� --------------- - -- - c✓r�0(f�( � — — = -- --- Tdres--- - ------ Installer — Driller ✓ /rAddress Type of Building C--t 7T c- ��0 /tee Dwelling----------------------------------------------------------------- Other - Type of Building------------------------------------- No. of Persons---------------=--------------------------------------- Type of Well__ i-�- r -- - -- --------------------------- Capacity----------------------------------------=----------------------------------- Purpose of Well----- -- ------------------------------- r Agreement: The undersigned agrees to install the aforedescribed individual .well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation — The undersigned further agrees not to place the well in operation until a Certificate of- .om,liance has been issued by the Board of Health. f-Z 'C Signed i=`--- -------- -- `� -- ------- -------------- --------------- 1 date Application A roved'B ' date Application Disapproved for the following reasons:-------------------------_----------_---_--------- ---- ____�_�______�^_________ ---------------------------------------------------- ----------- --------------- -----,— date Permit No.- - C��-- r —- ---. Issued---------- ----�— ---- --------------------------------- ' _ �,,.�'!` date.. r BOARD OF HEALTH TOWN OF BARNSTABLE THIS IS TO CERTIFY, That the Individual Well Constructed( ), Altered ( ) or Repaired ( ) b ----------------------- m--------------------------------- ---------------------------------------------- ---- / Installer - - n — - --------------------------------- at Jam'- ! -�- -(-' l J — ` TF=- ' a..� m1i' —= - — ----------------- -- ------ - has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation as described in the application for Well Construction Permit No. =--.i------Dated---------= ----------- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS,A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. - "10 DATE-------------------------------------------- ----------------------------------- Inspector - ------------------------------------------ - - ------ BOARD OF HEALTH / 1 i ;� + r TOWN OF BAR N STAB L,E ,,r l /� �A lVell.460truct ion Permit No. --- Fee--- t----w=--------- c& - Permission is hereby granted------- - - ---------------------------------------------------------------------------------------------------------------- to Construct�(�C), Alter ( ), or Repair( ) an Individual Well at: No. --------- - g Street' as shown on the application for a Well Construction Permit No.--------------- - --— =- - Dated------------------------��--- -vim' - - --------------------- -------------- ------ ----- -------- 1 Cy 0 Board of Health DATE-------f ~' - -°------------------------------------------- 2 ' o \ / vlo 0' )'j-P 35 L 1 � 1 � N �cN t r L pi r96 t 1 id jo4 t oti TM/\ O 1� \ r►o[.r � 1 ate / AV 1 , 1 via 0 1 fill PAP°sev � �ol. i .ol sro' � 7!1 ��lrlTTrTlnhnttnt�iTiTnT1/1T1ntIT11Ti1TTittTntiTllTltiTiTilnTtllT nti71111 nTilltiTTi1t11Tn11ttiTTIt1111t711t11Ttttttitnn111/tIn/1TH T1T177ttttititltnTl/11 nt ttt tittltftttlTlT7,,t111Tnt tii nti7TT ntitt Hunt lntrr ENVIROTECH LABORATORIES =_ Mass. Cert. #:N4A063 `- 449 Route 130 Sandwich,MA 02563 (508) 888-6460 CLIENT: tdhitney Wright _ LOCATION: Lot 13 Old Jail Lane = =` 256 Ocean Ave Barnstable, MA ADDRESS: _ - Hyannis, MA 02601 ti - COLLECTED BY: Fred Clifford SAMPLE DATE1-28-92 TIME- DATE DATE RECEIVED: 1-28-92 SAMPLE ID:M101 JOB 17: Npw hie11 _ WELL DEPTH: 100' RESULTS OF ANALYSIS =� Parameter Units Recommended limit Result E 0 Coliform bacteria/ 100 ml (MF Method) 0 pH pH units - ----- 6 0 .5 6.26 =� E Conductance umhos-cm 500 104 - Sodium mg ,L -- ---- 20:0 12. 1 BE Nitrate-N mg/L 10;0 0. 11 -_ c Iron mg/L 0.3 0. 17 c Manganese mg/L 0.05 c: — Hardness mg/L as CaCO 500 > 3 s c Sulfate mg%L 250" Potassium mg/L Alkalinity mg/L — 200 z=. Chloride mg/L 250 rE Turbidity NTU 5.0 E - � Color APC units 15.0 Background bacteria COMMENT: y EPA VOC 601/602 ug/L Chloroform= 4 EE see attached report Mi YES NO ' WATER IS SUITABLE FOR DRINKING PURPOSES FOR PARAMETERS TESTED. 0 DATE 2 l �r1U111ll11i111111U111111U11l111U1111UU111111U111111U1U111U111111U11illiUliUillitUilluliiiilUliiiliiiiiiiiiuiiiiiiiiiliiiitiliililiiliiiiidii3i+111! litiiliilliiililUilllUlitillUUliUUliU11Ul11Wi11iiiitUli111iii�� GROUNDWATER ANALYTICAL EPA METHODS 601 and 602 Volatile Organics (GC/PID/ELCD) Field ID: MW-101 Lab ID: 2575-01 Project: Wright QC Batch: VGA-926 Client: Envirotech Laboratories Sampled: 01-29-92 Cont/Prsv: 40ml VOA Vial/NaHSO4 Cool Received: 01-29-92 Matrix: Aqueous Analyzed: 02-05-92 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 1, 1-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 4 1 1, 1, 1-Trichloroethane BRL 1 Carbon Tetrachloride BRL 1 - Benzene BRL 1 1,2-Dichloroethane BRL 1 Trichloroethene BRL 1 1,2-Dichloropropene BRL I 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 I Chlorobenzene BRL 1 Ethyl benzene BRL 1 m+pp-Xylene * BRL 1, o-Xylene * BRL 1 Bromoform BRL I 1, 1,2,2-Tetrachloroethane BRL 1 1,3-Dichlorobenzene; BRL: 1 1,4-Dichlorobenzene BRL 1 , 1',2-Dichlorobenzene BRL I. QC SURROGATE COMPOUND SPIKED —'MEASURED ' `RECOVERY. QC LIMITS Bromochloromethane 30 . 29 97 % -83 117 % F1 uorobenzene 30 31 103' % 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). L. TOP OF FOUNDATION CONCRETE COVER CONCRETE COVERS '•,! a(.CAST IRON nri�*'h►x►7ar 77"M7m r'nsr*n77 2 MAX. 12"MAX PVOR C PIPE 48 4"SCHEDULE 40 PVC (ONLY) • PITCH PIP PER PIPE - MIN. LEACH PITCH I/4"PER.FT. PIT PRECAST • � « IN p -' LEACHING �\ • EL.. 7?.77. INVER INVERT PIT OR SEPTIC TANK EL.. z� BIOX EL.g33o >i EQUIV. ' C- eA EL INVERT/S�oa GAL. INV j47 INVERT G� wo 8: 3/4..T0fl/2 EL .. WASHED ; r EL`l'fP '� STONE w D�A• ��iC c� 6v t►t'u 20 .,� . �--- /Z D 1A--+-� PROR LE OF GROUND WATER TABLE ► SEWAGE DISPOSAL SYSTEM NO SCALE 7777 oil SOIL LOG ! WITNESSED BY : DATE •Tu!JE /j 'if/TIME ! oaA�1y. BOARD OF HEALTH 2 TEST HOLE I TEST HOLE 2D�A/CG ENGINEER ELEV. !j. a! ELEV. . y ,.d".a W0004&*,1 DESIGN DATA '. / Or v • I�� 9LSo,; " 2/0p El.Ro, o NUMBER OF BEDROOMS 1, D LX!'rae TOTAL ESTIMATED FLOW . . GALLONS/DAY 0o' .moo �-rE��Fi,�E i a I Ws}I ¢ BOTTOM LEACHING AREA 3 �. SO.FT. /PIT -' /�D, J � !/ r - J� >, s .v cS .S'Tbw S SIDE LEACHING AREA ��`�c>. ' �C? SO.FT./ PIT/C,f: ,.4 3 �3x. FC.f Hs GARBAGE DISPOSAL N°,*!-'�. .('s0% AREA INCREASE) LOQ7 ( \ `'vo TOTAL LEACHING AREA s4''T, SU SQ.FT `•� I G G 6 l I iN" dC.lfL.�a PCOLATION S MIN/INCH l LEACHING AREA PER PERCOLATION RATE L�tSl7"i SO.FTJ ,, f I i,1 WATER ENCOUNTERED `. J� NUMBER OF LEACHING PITS ) APPROVED . . . . . . . . . . . BOARD OF HEALTH p,t ► S DATE Pifr �C i AGENT OR INSPECTOR 0 OF (I cy ' SepnK 1r 7 \ POLO 114 V M.PALL - 1. /0 1 \ �_ 1 ,i 9�Q► l FPO I Joe a Sep p ► /7- l-'-' ter �N �3i=�2w-s'r<a � � • s.� . I,,r/wi7--oV w�'.ct/r� M7Z-- �L�i/Arlo1�5 W 9SETJ o�/ S ltL7 �• iZ.rl' o�yoF� CERTIFICATE OF ANALYSIS page. Barnstable County Health Laboratory •'�s�eHus�'! Report Prepared For: Report Dated: 06/03/2002 Order Number: G0214733 Joan Wright P.O.Box 1045 Barnstable, MA 02630 Laboratory ID#: 0214733-01 Description: Water-Drinking Water Sample#: 14733 Sampling Location: 331 Old Jail Lane,Barnstable Collected: 05/31/2002 ollected by: J.Wright Received: 05/31/2002 Routine ITEM RESULT UNITS MDL MCL Method# Tested LAB: IC Lab Nitrates 0.4 mg/L, 0.1 10 EPA 300.0 05/31/2002 LAB: Metals Copper 0.4 mg/L 0.1 1.3 SM 311113 06/03/2002 Iron 0.1 mg/L 0.1 0.3 SM 311113 06/03/2002 Sodium 11 mg/L 1.0 20 SM 3111B 06/03/2002 LAB: Microbiology Total Coliform Absent P/A 0 Absent P/A 05/31/2002 LAB: Physical Chemistry Conductance 159 umohs/cm 1 EPA 120.1 05/31/2002 pH 7.2 pH-units 0 EPA 150.1 05/31/2002 Note: Water sample meets the recommended limits for drinking water of all above tested parameters. Approved By: s (Lab Director) ��7I LOtJ L `S Superior Court House, PO.Bog 427, Barnstable, MA 02630 Ph: 508-375-6605