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HomeMy WebLinkAbout0361 OLD JAIL LANE - Health r � ry e, d Jail Lane {, - Barnstable .: Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 361 Old Jail Lane a M Property Address p.a Bruce M. Lane to Owner Owner's Name -j information is �� /� ,Q required for every West Barnstable ��/ L Ma 02668 12-29-16 � page. City/Town, �" State Zip Code Date of Inspection ►+ W 07 Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: key to move your cursor-do not Matthew Gilfoy use the return Name of Inspector key. B&B Excavation Q Company Name 374 Route 130 Company Address Sandwich Ma 02563 City[Town State Zip Code (508)477-0653 SI 13640 Telephone Number License Number �. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority or- 12-29-16 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 �0J'�w rs Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 361 Old Jail Lane Property Address Bruce M. Lane Owner Owner's Name information is required for every Nest Barnstable Ma 02668 12-29-16 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: System was in working order at time of inspection. 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): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 361 Old Jail Lane _ Property Address Bruce M. Lane Owner Owner's Name information is required for every West Barnstable Ma 02668 12-29-16 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 361 Old Jail Lane Property Address Bruce M. Lane Owner Owner's Name information is required for every West Barnstable Ma 02668 12-29-16 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/day flow t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts WTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 361 Old Jail Lane Property Address Bruce M. Lane Owner Owner's Name information is required for every West Barnstable Ma 02668 12-29-16 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 portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 361 Old Jail Lane Property Address Bruce M. Lane Owner Owner's Name information is required for every West Barnstable Ma 02668 12-29-16 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (Actual) _4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form_- Not for Voluntary Assessments ,M 361 Old Jail Lane Property Address Bruce M. Lane Owner Owner's Name information is required for every West Barnstable Ma 02668 12-29-16 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d See below 9 ( Y 9 (gP ))� Detail: "WELL WATER" Sump pump? ❑ Yes ® No Last date of occupancy: 9/16 Date Commercial/Industrial Flow Conditions: Type of Establishment: NA. Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 361 Old Jail Lane Property Address Bruce M. Lane Owner Owner's Name information is required for every West Barnstable Ma 02668 12-29-16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Last pump unknown Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 361 Old Jail Lane Property Address Bruce M. Lane Owner Owner's Name information is required for every West Barnstable Ma 02668 12-29-16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1986 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 4 feet Material of construction: ® cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: >50'feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): Depth below grade: 3 feet Material of construction: ® concrete El metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, liist age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500gallons Sludge depth: 8� t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 361 Old Jail Lane Property Address Bruce M. Lane Owner Owner's Name information is required for every West Barnstable Ma 02668 12-29-16 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 28 Scum thickness 0 11 Distance from top of scum to top of outlet tee or baffle NS Distance from bottom of scum to bottom of outlet tee or baffle NS 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.): Tank was in working order at time of inspection with liquid level equal to outlet invert. Tank is not in need of pumping at this time but should be pumped every two years for maintenance. Grease Trap (locate on site plan): Depth below grade: NA feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 361 Old Jail Lane Property Address Bruce M. Lane Owner Owner's Name information is required for every West Barnstable Ma 02668 12-29-16 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: NA Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑, Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 361 Old Jail Lane Property Address Bruce M. Lane Owner Owner's Name information is required for every West Barnstable Ma 02668 12-29-16 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 0 11 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.): D-box was in working order at time of inspection with no sign of previous back up. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): NA * 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: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 361 Old Jail Lane Property Address Bruce M. Lane Owner Owner's Name information is required for every West Barnstable Ma 02668 12-29-16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: (2) 6'x6' ❑ 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.): Leaching was in working order at time of inspection. Pit 1 had 8" of standing water when inspected with no sign of high staining. Second pit was not opened. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration NA t Depth —top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 361 Old Jail Lane Property Address Bruce M. Lane Owner Owner's Name information is required for every West Barnstable Ma 02668 12-29-16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: NA Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealths of Massachusetts w Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 361 Old Jail Lane Property Address Bruce M. Lane Owner Owner's Name information is required for every West Barnstable Ma 02668 12-29-16 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately A3.02 83o 72' AS• � 135y 84' B WELL GARAGE A >150`from SAS DRIVEWAY t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 361 Old Jail Lane Property Address Bruce M. Lane Owner Owner's Name information is required for every West Barnstable Ma 02668 12-29-16 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: >13'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: 5-1-85 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: You must describe how you established the high ground water elevation: Plan on file with BOH. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 5 361 Old Jail Lane Property Address Bruce M. Lane Owner Owner's Name information is required for every West Barnstable Ma 02668 12-29-16 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 ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 AsBuilt Page 1 of 1 ASSESSOR'S MAP N0. 1`17 PARCEL ' / a q17 �' • f LOCATION o - �bSEWACE PERMIT NO. �\YILLAGE 1NSTA IIER'S NAME i ADDRESS I U I L D E R OR OWNER `DAtE PERMIT ISSUED DATE COMPLIANCE ISSUED T 777e9l y1` 4 1 } http://issgl2/intranet/propdata/prebuilt.aspx?mappar=277029&seq=1 10/l/2013 ASSESSOR'S MAP NO. V7�7 PARCEL �' , q 7 a'4 9 LOCATION p 3 iEWAGE PERMIT . N 0- ',N-YILLAGE Q 7 INSTA LLER'S NAME i ADDRESS d U I L D R E OR OWNER NER ` DATE PERMIT ISSUED 12- J :L DAT E COMPLIANCE ISSUED 2 e � v r v ' ASSESSORS MAP NO: <r .f 277 Nam: r--7j► k�ARCEL NO.: -1 F1zs......4.... THE COMMONWEALTH OF MASSACHUSET,;S BOAR® OF HEALTt Town Barnstable ............._.. ..........._..._._....OF.......:,................................................................................ ApVtiratiun for %yus al Works Tvniitrurfiun Permit Application is hereby made for a Permit to Construct ( X) or Repair ( ) an Individual Sewage Disposal Sys tem at: Lot 17 Old Jail Lane ..... _......_.......... . -------•--•-•--------- ............. - • ..............__. oc in-A ress or t No. Joseph anuy now care of Coy's Brook nc. 24,Fpr y, „�y�¢„ Owner Address SOUtT7 armouth, MA 02664 Installer Address 76 745 Type of Building Size o ............................. Sq. feet U Dwelling—No. of Bedrooms..-Fgur...(AA......................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building ............................ No. of ersons............................ Showers — Cafeteria a Other fixtures . --•-•-------••------------------•-----...----P---------------------------•-----•--------------- ( ( ) ... ..._gallons per person per day. Total daily flow........ ..............................gallons. W Design Flow------....--•---------------------- -- g P P P Y• Y � Disposal Trench tic Tank—Liquid capacity.-1.500�adl�hns" Lengt ToOtalLengthidth-5_'.$..--:-Total leaching area.__Depth--5'_8q'_f�: Seepage Pit No........ Diameter....B.-.0......... Depth below inlet.._G._D._..__... Total leaching area..4DQ.........sq. ft. Z Other Distribution box ( x) Dosing tank ( ) '-' Percolation Test Results Performed by.... LXQ. fey................................................. Date..5J.1I85..... ,-a Test Pit No. 1.....2.........minutes per inch Depth of Test Pit.....13......... Depth to ground water.....nane......... *-4, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ R+' ..........-.................................................................................................................................................. ODescription of Soil------ ;-la-'- ©claal--------------------------------•-----•--------------------•--•-------------•--------------------------------------------.------ U •-•------------•--•--•••......................8.'...Dada.Ua._Saud---w/----Qrave1---------------••---•----....----•------- Z ---------------------------------------g,---- -V---Me-d -ITM--San-cl-----••---------------------------------------------------------- ••----------------•------------------•---•----------- U Nature of Repairs or Alterations— nswer when applicable............................................................:.................................. ---------------------------•-------•----------------------•------------•--...----...----------•-------------•----------------------....------------------------......-----------------------------..... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System.in accordance with the provisions of'LNLL 5 of the State Sanitary C de— The undersig d further agrees not to place the system in operation until a Certificate of Compliance has bee i sued by the boar of health. Signed ........ ..........----- ate Application Approved BY.................................-- � � = ------.---•--... �-�- Date Application Disapproved for the following reasons:..........................................................................................•--.........__....._ ....-•-•------•------•--•--•--•-•-•-------•--•--.....---•--------•---------•.............................I.....................•-•-------•-----•-...-------------------•-••--•----------------...-------- - Date Permit No.------ .....� .� ._...... Issued. - - Date N --.�� 3-1 FEs..........................u THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTFi Town:... ....................OF............Barnstable ................... Appliration for Disposal Works Tonstrartion "amit Application is hereby made for a Permit to Construct ( X) or Repair ( ) an Individual Sewage Disposal System at: Lot 17 Old Jail Lane ... - ........._..................... ......................... •--••----• -- -.--.-.-.---.------•------•---..---•• - -• - .............................._. Location-Address or Lot No Josep I•ans JudX Snow care of CoX's Brook• .lncr 24..Forsyth.Ave-:- South ..... - .. ..... ..._..... Owner Address Yarmouth Ma W - ......... . ............ .. ............... ----- ---.-•-- ----.--- •--- 0 664 Installer Address 76 745 Type of Building Size Lot.........L.................Sq. feet Dwelling—No. of Bedrooms....Four(4) .Expansion Attic ( ) Garbage Grinder ( ) a'4 Other—Type of Building ........_ No. of persons............................ Showers YPe g ------------------- P ( ) — Cafeteria ( ) Otherfixtures -----•-----------------••--------...---•----------------•--••••-••••••••---••---•-•-•---•----••--•••...-••----•----._........--••••-•-•..._....------ W Design Flow............................................gallons per person per day. Total daily flow...............440........._............fWlons. WSeptic Tank—Liquid capacity.1500._gallons Length..1 Q'6"___ Width..5.'8....... Diameter................ Depth 5..5 ...... x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No.....2....:........ Diameter...8'A.......... Depth below inlet.....(a.'-Ll.'-'-...... Total leaching area......4.QQ......sq. ft. Z Other Distribution box ( X) Dosing tank ( ) Percolation Test Results Performed by....Ed..Kelley................................................ Date...51.1/.85.....F-4441--.. ,.a Test Pit No. I......2........minutes per inch Depth of Test Pit----la........... Depth to ground water......nane......... (� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ p4 ....----....•••••••------•-------•••-•..............••••-•-•---.....-•••••-••--•-•-••---......•-•....•-•-•...--•••••-••--•--.....-•--•--•-•••-•----•-•••-•••. D Description of Soil......... ............................................. V ..........................................4.'_.-5.'...Hedlua..Saad..w/...Graye Grayel................................................................................................ UW -----------------------------------------8-'.-1 .'--.Me-di um..San-d-----•-•-------------------...---------------------------...------.......:------•---•------..........------------•--- 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"-ITLE 5 of the State Sanitary Code—The undersig' ed further agrees not to place the system in operation until a Certificate of Compliance has/�bee ssued by the boar of health. Signed• r�::�......... ------- -------•--•--------.:�:- Application Approved BY ---•-•.....--=`........... -•-- ..:..J �..._.._... ...--- a- Date Application Disapproved for the following reasons:-------•-------------------•---•---....-----•-•-------...------------.......-••••---. .............__ r . .......--•----------------•-•---•------•--•..•••• -•-•---•--.....-•••••--•- •••--•----...•-------•--...------•-----•-•------...----.........--•-.............--... .-................... 0 Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS v BOARD LTH - VIKD kis ..........................................OF..................................................................................... (Inrtifiratr of Tomplittnrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by.. �„�. ..........-••-...... ••••------....--••••.......•••--•---••-•---•--•..................................................••--•-••-•-.......•--••...... ........ Installer at•••--••.L4--•---J-•7•••••�.. .... �'l.L- 1�..�---------.�Xk�I�--------------------------------------------------------- has been installed in accordance with the-provisions of TITLE 5 of The State Sanitary Codes described in the application for Disposal Works Construction Permit No.�__ 771 O R--•-. Z- PP P v�----------- dated------�-��------��G.Ca.-•-------•• . THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCT)ON SATISFACTORY. l DATE................... ... ��........................... Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS �----- BOARD OF HEALTH .N.........OF........ � ... No ..�. FEE................ Disposal Works Tonstrnrtion f amit Permission is hereby granted...........V .E.. ....................... to Construct ( ) or Repair ( ) an Individual SewDisposal S at No..................................4,-p._ ...........L �l. C?-�•- ----- ---i/�' .�-...... Street as shown on the application for Disposal Works Construction Permit No................... gated..... ...... .._.._.........._._........ ...----- Board of Health DATE...... .---•-• ./..-)�pna ........•--•-- FORM 1255 A. M. SULKIN, INC., BOSTON �7. I 1, Department of EnvirpninentatfMhmagement%'Division of WaterResources + WATER WELL COMPLETION REPORT - I WELL LOCA�>«kON s, Address ^ r- .< ! . ., • Citylfown tnv �Quedrangle Map` Ow,n . .er �l {Address, : .. Sr. �,• * = ELL.USE < GN; ODATED WELL- tDomeic ❑ alPc *x.'^ Type oVWater bearing,Rock Other Water-bearing Zones ` e a y a . � � �: � _ �' zr. � •� .:�' Gkd Method Dnll,ed - - 11 From TO- ... „`�2'1 From b To{� rl Date D,nlled � � 3,31) From TO F 41 From CASIN:G 3s � Depth,to Bedrock h , 4f 4-e6s b Diaet mer /- .. r..' type-° lOdct 3: UNC'ONSOL:IDAirbb Wt ' .'.f STAlTI'C WATER LEDGE"L Water-bearing Materials "* Feet below land surface Sand time❑„ m iu edm', oarse' Date measure7l- ;G:ravt f,rne Q 'mednurn course Q Screen GRA\7+EL PACK WELL Slot � length_ from-' to Yes wit Screen•(ror 2nd scIreen) r' W.A.TE`R QUA, LITY TEST .MADE Slot I:ength, — from to Chemical , Biological [] Depth-To Bedrock s t. kq• r, , y +PUMP.TEST v ! , ar4_ t7:.r,4w". s,,,«w f Orawd"own feeI Efter,pumping �ciay;s " �hoursmai� G#'M How measmred' l `Recgvery feet after `hours LOG of F(fRMAT1ONS (On'well or'wafer.) w°* • � � r � � °x� pr,�t. ^�vIl�j/ F�rRl t i n C* !''t ! +'L¢�'.I l K� ? , .,• � .Addres „ Registroti n No.-46 e dzik�Ad u Peraaor,s�ignature' • �r� ease'p�rnt rrm y + �; a c 25M 10 85 807101 BOARC,QF HEALTH .<A L 2a �,,�.,,'�,.. .;« -e?�r�s .,•s.'�. 4; t Lo Number: Bottler E324 Date: April 16, 1986 9 of $ARti BARNSTABLE COUNTY HEALTH AND ENVIRONMENTAL DEPARTMENT �Z 7 SUPERIOR COURT HOUSE V � BARNSTABLE. MASSACHUSETTS 02630 Asa DRINKING WATER LABORATORY ANALYSIS PHONE: 962-2311 Ext. 7 Client: Coys 'Brook 'Company Collector: Edward T.°`Meehan Mailing" Address: 24 'Forsythe Avenue Affiliation: "_wPll ' dril10Kr South :-Yarmouthh MA 02664Time & 'Date of Collection: 4l14lR�' 36` a m: ;a:,-;Pie 394-8442 Type of Supply: _U�1 Sa:,:p,e Location: Lot 17 Old Jail Lane Well Depth: 921 Barnstable, MA Date of Analysis: 4.14.186 12-15 pm- PARAMETER ' " SAMPLE-RESULT ".RECOMMENDED LIMITS Total Coiiform Bacteria/100 ml I 0 0 5.7 Ph Ccnductivity (micromhos/cm) ,. ,... 82'.0 " F 5000 - Iron m) <.1 0.3 Nitrate-Nitrogen ( m <.1 i _ 10.0 Sodium m _ 10.0 20.0 I . X Water sample meets the recommended limits for drinking of all above tested paramete II . Based only on results. of the parameters tested for this sample, the water is sui tabl e for drinking. ;but may present 'the' problems checked below:, A. (dater sample has higher 'thhean average levels of Nitrate. Future monitoring g is ' P 9 recommended (2-3 times per year) to establish any upward trends. F. The low pH of the water may shorten the useful life of the house's plumbil,y. C. Water may;.present' aesthe' tic problems (taste, odor, staining) due ''to �. Water sample has high levels of sodium. Persons on low sodium diets should consult their doctor. II1 . Due to one' or more of the .reasons checked below, this water sample is unfit for human cons umptic,n . ` ''A:' High Bacteria 'B: High Nitrates F LL_MARKS: Depor n%nt s';a,. nvi cr. dcm interpretations or conclusions made by anyc else concerning these results without written co: CC: Barnstable Board of Health. CC: Meehan Well Drilling 117/85 14 Laboratory Director 1 ti .,tea•-,4 1141 Explanation of Test Results \5� Total Coliform Bacteria ' Coliform bacteria are an indicator of the sanitary quality of a water supply. Water supplies may become contaminated from-;malfunctioning septic systems, cesspools and surface runoff. A total coliform count of zero indicates that your water supply is safe and approved for human consumption. A total coliform count of greater than zero is most often the result of accidental contamination of the sample bottle through improper sampling methods. For this reason, it would be advisable to retest any well water that is not approved: pH pH is the measure of acidity or alkalinityof the water.On the pH.scale,the number 7 is neutral,less than 7 is acidic and more than 7 is alkaline.-The pH of water on Cape Cod tends to be acidic in the range of 5.0 to 6.5. Conductivity Conductivity is a measure of the dissolved salts in solution.Amounts in excess of 500 micromhos/cm are generally considered unacceptable and may have.a laxative effect upon users. - Iron The presence of iron in water in concentration of.3 ppm or greater may: give the water a bittersweet astringent taste, cause an unpleasant odor, often gives the water a brownish color and cause staining of laundry and porcelain. The average concentration of iron in Cape Cod's water is .2 - .6 ppm. Although the presence of iron in water may cause the problems listed above, it is not considered deleterious to health. Iron may be removed by use of an iron removal system. Nitrate-nitrogen Tile Massachusetts Drinking Water Regulations have set a maximum contaminant level for nitrates at 10 ppm. Excessive concentrations may cause methemoglobinemia (an infant disease) and have been suggested to form potentially carcinogenic nitrosamines. Contamination sources include fertilizers, cesspools and industrial wastes. Copper Due to the acidic nature of the water on Cape Cod,.copper.tends to leach from pipes. This normally does not present a health hazard; however, concentrations in excess of 1.0 ppm may cause a metallic taste and/or a bluish-green stain on porcelain fixtures. r Sodium A concentration of sodium over 20 ppm is only of concern to people who are on a low, sodium diet. if the water supply has more than 20 ppm sodium, it is up to the people who are on such a diet to find another source of drinking water or contact their doctor to determine if consuming the water is advisable. Co.icentrations exceeding 50 ppm indicate that there may be ocean water or road salt runoff water getting into the well. y".,;... , war DESIGN DATA SOIL TEST DATA �• � (q Number of Bedrooms q Fite of Test P -4.4-�/ , <- Total Design Flow 4,40 gpd Tested by E D K L EY ti a� arc �, OO Witnessed by Septic Tank Required 1.5x+4o =460 gal. mac, Septic Tank Provided /SOo gal. Percolation Test Depth of test o g �'�' ,y4 c, Leaching Facility Provided: Rate min./in. s= �o o ��rType Fg c r tT Test Pit Data ti c A Eery �, / $� F'iNAk CRgoP Dimensions saoPz 3/a +est Pit #1 Test Pit #2 y 4" Garbage Grinder 1 /Wi11Not Be Used Elev.: Elev.: -q°� Y®„ar w .rg (5C% area increase is req'd with grinder) Slope - J/ft . . I'r�#N Leaching Area Provided: Bottan k x So = /oo sgft Septic Tank s Sidewall •a x r_�n z 30o sqftOxf WooD�oA M •fir ISbO gal. Mist. 3/4itto 1 1/ 2" layer Total 4-00 soft � / /Box Stone . Leachin 'g,� 8 to 1 4 Stone it���®„..:;®�., •f ;�: d Pit ® Lathing Capacity Provided: '''` :1 1Ooo a •� Bottom/oo sgft x 1,D 8Pd/sgft = ME� 7R XEAL WO ew Sidall sgft x�gpd/soft =25o gpd w c Total aLosqft 9PPI 6 io C Bottom of Pit Breakout Calculation: 15o x 8/170 =/a O _.. _ _ ._ 3 NOTES r E s �°J �4 P �, E.S.G.W.L. 1. All installations shall„ c Oviform to the minimum Observed water y6,v Observed water lop BL•! / / « pG r requirements of The State Envirannental Code, E.S.H.W.L. E.S.H.W.L. Title 5, and the Town of Board of Health. property Y• n' Benchmark Elev. 75 ASS W I E D 2. This is not a o line Bound information fran A PLAN of LAND I" ! BARNsTA�E, MA. FOR DAVIA BRUSN, PMOPobEp wATCt L E ' / / ! / / �l / l file-'a LA) SEPr. 14, )784 We ED V,F44EYJ RE's. � F LAND SWI?VEYQR. 6 EXIS711Y6 Co%(1'dyffls I 1 1 I t ' ! / / ( G 3. A10 1A1EkL-s w)7wlu /so' of SEPTIC SYsTEhts �_ PdroPRSED CONTOU)TS ' { w a.; s o � '� 1 F Ew 'N low- 10. l \ s r < Ta BA�vsT>�$e�,pa. J, `-1 / / dT/q LOCUS 17 SEWAGE DISPOSAL SYSTEM o LoTla DESIGN Y At o CONsT on: LOT 17 for :TosEPM R 1-UDYStioul OLD JAIL GAME CARE OF: , °, , ,,� SARNSBrLE,, MA COPS 8kooK, I'Nr'. H l / TA/ FORSYT14 ,A VE. J / S. YARMOU7791 M A Noa 71�. • L677 14 No cOk_ST; r; CB i � \ r r� engineering GREOGE G. -► LOMBARBO SANITARY Na 32533 � r--"' Q 'I/{1 L' L Ar� S/COAL �r4 o Envirnomental Consultants �'=/ M y" 24 Forsyth Avenue # South Yarmouth # MA # (617) 398-5215 PLAN sc.A�.� ,�,���,� � ,�-�'� a