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Home My WebLink About0059 OTTER LANE - Health r159 Otter-Lane Barnstable A = 351 - 010 - 003 C& Ok Cot nnvnWeWth Mkrswchusle as a r , Subsurface Smage Wbobsal System For -Not for Voluntary Assessments Mz 59 Otter Ln. Property Address Maureen McCarthy h Owner Owner's Name __-- information is,eCumin uid IVIA 02637 11/11/2014 required for every � —. page, Cityrrown state Zip Code^ Date of Inspection ' Inspoction results must be submitted on this form. Inspection fames,may not be altered in any way.Please see completeness checklist at the end of the form. Important:When A. GeneM flil oi1'1 1 1o� filling out forms on the computer, .. L use only the tab key to move your 1. inspector: n cursor-do not Paid Marts use the return Name of Inspector — — — key. Neigtiborhood'Waste Water � Gorrlparry Dame --!�----,._.- ----- — — --- 350 Main St Company Addrie --- — --- W.Yaiwmth MA 02673 _ City/Town State Zip Code 508-775-2820' S15016 Telephone Number License Number B. %0erfification- 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 CHR 15.000).The system: ® Passes ❑ Conditionally Passes [' Fails Needs Further Evaluation by the Local Approving Authority, 11/11/2014 ---� 'Inspector's Signature Date —-- The system inspector shall submit s 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 DER The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****Ttds report only describes conditions at the time of inspection and udder the conditions of use at that thine.This impection does i-ot.addiess how the systern will perform in the future under the same or different co ions of use. t5ins•3/13 Title 5(Micial Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commorrweafth of Massachusefts Title 5 Official Inspection Form Subsurface Sewage Disposal System Forni-Not for Voluntary Assessments 59 Otter Ln. Property Address Maureen McCarthy Owner Owner's Name information is required for every Cummaguid _MA 02637 11/11/2014 page City/Town 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 31.0 CMR 15.303 or in 310 CMR 15.304 exist..Any failure criteria not evaluated are indicated below. Comments: No failure criteria met 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 r 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 andover 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•3113 , Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 , Commonwealth of Massachusaft -- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 59 Otter Ln. , Property Address Maureen McCarthy Owner owner's Name information is Cummaquid MA 02637 11/11/2014 required for every — page. Cityrrown 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(cunt.): T❑ 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): El broken pipes)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): FI 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., i 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 wafter ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official tnspection Form:Subsurface Sewage Disposal System•Page 3 of 17 ' ' ? Commonwealth of Massachusetts Title 5 Official Inspectlion Foy Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 59 Otter Ln. Property Address Maureen McCarthy Owner Owner's Name information is required for every Cummaquid MA 02637 11/11/2014 page. City/Town State Zip Code Date of Inspection B. Certification (cunt.) 2. System will fall unless the Board of Health (arid 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 systemp 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**. i 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•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 4 of 17 f Commonwealth of Mawachuseft Title 5 Official Inspection Form Subsurface Sewage Disposal Systems Foam Not for Voluntary Assessments 59 Otter Ln. p Property Address Maureen McCarthy Owner Owner's Name information is Cummaquid MA 02637 11/11/2014 required for every _ _ _ page. City/Town State Zip Code Date of Inspection B. Certification (coat.) 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 tribute to a surface water supply. � ry , . ❑ ® Any portion of a cesspool or privy is within a Zone 1 of'a public well ❑ ® _ An portion of a cesspool or privy is within 50 feet of a rivate water supply well. p Y P P Y P PP Y ❑ ® 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 pprn, - provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] i ❑ ® The system is a cesspool serving a facility with a'design flow of 2000gpd- 10,000gpd. [D 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 merit 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'systern 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 'I5.3.04. The system owner should contact the appropriate regional office of the Department. ; t5ins•3/13 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts. Title 5 Official Inspection Form Subsurface Sewage Disposal System Forma Not.for Voluntary Assessments 59 Otter Ln. Property Address Maureen McCarthy Owner Owner's Name — information is Cumma uid MA 02637 11/11/2014 required for every � - 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 R ❑ 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? y ® 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? ® El 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 6nfonnation Residential Flow Conditions: Number of bedrooms'(design): 3 Number of bedrooms (actual): -4 11 DESIGN flow based on 31.0 CMR 15.203 (for-example: 110 gpd x#of bedrooms): 0gpd 330gpd f - t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 i . Commonwealth of Massachusetts Title 5 Officiffial Inspection For Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M� 59 Otter Ln. ` Property Address Maureen McCarthy _ Owner Owner's Name information is required for every Cummaquid MA 02637 11/11/2014 page cityrrown State Zip Code Date of Inspection D. System information a Description: 2 Number of current residents: 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 Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage 2013=93gpd 9 ( Y 9 (9pd)) 2014=88gpd Detail: Sump pump? _ ❑ Yes ❑ No Last date of occupancy: Current Date Corr merciallindustrial Flow Conditions: Type of Establishment: Design flown(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•W13 Title 5 Official,Inspection Form:Subsurface Sewage Disposal System•Page.7 of 17 Commonweakh of Massachasets i Title 5 OfficialInspection Form _ Subsurface Sewage Disposal System Form Not for Voluntary Assessments 59 Otter Ln. Property Address Maureen McCarthy. Owner Owners Name information is Cumma uid MA 02537 11/11/2014 required for every 4 — page. City/Town State Zip Code Date of Inspection D. System Infoirmation (cost.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: BOH 2O14 Was system pumped as part of the inspection? ❑ Yes S . No If yes, volume pumped: gallons ` How was quantity pumped determined? Reason for pumping: R Type of System:: i ® Septic tank„distribution box, soil absorption system ❑ Single cesspool 01 ❑ 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 i Commonwealth of Massachusetts Title 5 OfficialInspection Form Subsurface Sewage Disposal System Fora-Not for Voluntary Assessments 59 Otter Ln. Property Address Maureen McCarthy Owner owner's Name information is Q required for every Cumma uid MA 02637 11/11/2014 page. Cityfrown State Zip Code Date of Inspection D. System information (cunt.) Approximate age of all components, date installed (if known)and source of information: 28 Years per plan on file at BOH. . -t. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 1 53" Depth below grade: feet Material of construction: ❑cast iron E 40 PVC ❑other(explain): Distance from private water supply well or suction line: +10 { feet n Comrrients'(on condition of joints, venting, evidence of leakage, etc.): Line inspected with sewer camera and was found to'be clean, properly pitched with no sign of root intrusion. Septic Tank(locate on,site plan): ' Depth below grade: 48" — feet Material of construction: concrete ❑ metal . ❑ fiberglass ❑ polyethylene ❑other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yesr ❑ No 1500Gal H-10 Dimensions 3„ Sludge depth: ✓ t5ins•3113 Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 F � I Commonwealth of Massachuseft Title iclal Ins ct'on Form, , Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 9 �a Y ry V0 59 Otter Ln. x Property Address --- —-- Maureen McCarthy Owner Owner's Name information is Cummaquid MA 02637 11/11/2014 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) - Septic Tank(cunt.) ' r • , Distance from top of sludge to bottom of outlet tee or baffle 31 — .. pee .. 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 ®� How were dimensions determined? Sludge Judge/Tape Comments(on pumping recommendations, inlet and outlet•tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 1500Gal H-10 Tank in good condition. PVC tees in place and clean. Tank at normal operating level. Inlet cover 12" below grade and outlet cover 8" below grade. — Grease Trap(locate on site plan): � r Depth below grade: feet Material of construction: ❑concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑other(explain): Dimensions: Scum thickness Distance'from top of scum to top of outlet tee &baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-3/13 w Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 f 0 Commonwealth of Massachusetts Title 5 Official Inspection Form. . Subsurface Sewage Disposal System Form-Not for Voluntary Assessents 59 Otter Ln. Property Address Maureen McCarthy Owner Owner's Name information is �required for every Cumm uid MA 02637 11/11/2014 ' page. City/Town State Zip Code Date of Inspection D. System Information (cunt.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): r Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons 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 attachad? ❑ Yes ❑ No t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 t Commonwealth of Massachusetts Title 5 Official Inspe'dion Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 59 Otter Ln. f Property Address — - Maureen McCarthy Owner Owner's Name information is Cummaquid _MA 02637 11/11/2014 required for every — page. Cityrrown State Zip Code . Date of Inspection De System Information (cont.) 7 Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 il 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.): H-10 DB-5 in acceptable condition.-Box is level and solid. Minor signs of solids carryover with no sign of overloading or.hydraulic failure. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes - ❑ No* Alarms in working order: ❑ Yes 0 No*' Comments(note condition of pump chamberi condition of pumps and appurtenances, etc.): *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 Fonn:Subsurface Sewage Disposal System•Page 12 of 17 y Commonwea9th of Massachusetts Title 5 Official Inspection Fr Subsurface Sewage Disposal Systems Form-Not for Voluntary Assessments yap 59 Otter Ln. Property Address Maureen McCarthy _ Owner Owner's Name information is required for every Cummaquid MA 02637 11/11/2014 page. CityrFown State Zip Code Date of Inspection D. System Information (cunt.) Type: ® leaching pits number:, 1-6x6 ❑ Teaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: innovative/altemative system E Type/name of technology: — Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): 1-6x6 Leach pit with 3'of standing liquid in it at time of inspection. No obvious signs of staining above 4'. No sign of overloading. Cesspools (cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration z Depth—top of liquid to inlet invert — Depth of solids layer — layer Depth of scum la P y Dimensions of cesspool Materials of construction Indication of groundwater inflow- ❑ Yes ❑ No t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts , Title Official Inspect'16h Form ^� ) Subsurface Sewage Disposal Systern Fora -Not for Voluntary Assessments' 59 Otter Ln: Property Address ------ Maureen McCarthy Owner Owner's Name -- -- information is Cummaquid MA _ 02637 11/11/2014 required for every -- page. Cityrrown 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: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level„of ponding, condition of vegetation, etc.): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachuseftsf Title 5 Official Inspection Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 59 Otter Ln. Property Address Maureen McCarthy Owner Owner's Name information is Cummaquid MA 02637 11/11/2014 required for every — page, Citylrown State Zip Code Date of Inspection D. System Information (coat.) 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: t ❑ hand-sketch in the area below ® drawing attached separately t5ins-3/13 Title 5 Official h6ection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachuseft Title 5. Offlocial Inspection' r Subsurface Sewage Disposal System Forma -Not for Voluntary Assessments - 59 Otter Ln. P Property Address Maureen McCarthy Owner -_ -- - _ Owner's Name information is required for every Cummaquid MA 02637 11/11/2014 page. City/Town State Zip Code Date of Inspection D. System information (cone.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high groundwater: 19 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: Soil Log ®ate 6/20/1986 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: Test Hole data per plan on file at BOH Dated 6/20/1986. Groundwater encountered at 19'. Bottom of leach pit at 12'. (Minimum of T groundwater separation. Before fling 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 Title Official Inspection Form, . Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 59 Otter Ln. Property Address Maureen McCarthy { Owner Owners(dame information is Cummaquid MA 02637 11/11/2014 required for every , page. Cityrrown 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 - i t , t5ins•3/13 Title 5 Official Inspecfion Forth:Subsurface Sewage Disposal System•Page 17 of 17 7- TOP OF FOUNDATION CONCRETE COVER o,' CONCRETE COVERS ?,86 e m 4"CAST IRON 12r� 12"MAX. "' a ° OR SCHEDULE 40 4"SCHEDULE 40 PVC.(ONLY) P•V.C. PIPE� PIPE - MIN. LEACH° PITCH 1/4-PER. PITCH 1/4"PER.FT. PIT o•� PRECAST NVERT r LEACHING ` o EL..ze./�.. INVERT INVERT ? - Q•4 PIT OR o . SEPTIC TANK. DIET. ° EQUIV. ELX4INVERT BO1C So—� 0: .o. GAL. INVERT a, a a; EL....... .. ? „ INVERT :.bo 3/4"TO 11/P EL759 e: sWi o �- o WASHED e w STONE 6'DIA. . --m-' —� PROR LE OF GROUND WATER TABLE ° SEWAGE DISPOSAL SYSTEM Norte- •gzc irxPNiz�,ovs N0 SCALE !3'ey�tip 7-V (.sy�ev S®AL LOG ®Y ' �"> � WITNESSED . DATE �''-�; f9 � TIME./o:¢s .A ! �� i`1�/� %9..^�. BOARD OF HEALTH TEST HOLE I TEST.HOLE 2 ENGINEER ELEV,. .3a. o� . . ELEV. .Zg I. . . DESIGN DATA' NUMBER OF BEDROOMS TOTAL A 3 o T L ESTIM MATED FLOW . . . . . . . . GALLONS/DAY BOTTOM LEACHING AREA ��' . . S0.FT. PIT/ i /c/? M6-P. SIDE LEACHING AREA SQ:FT./ PIT/47/Q.P.D. GARBAGE DISPOSAL .ti4^.1E. . .(50% AREA INCREASE) SAivA w.� TOTAL LEACHING AREA . '. .`'��. . SB.FT azs wslTor�- Lzo" a�2./4 c C PERCOLATION RATE=. T1G'' ?'✓.o . MIN/INCH a4 3 5 LEACHING AREA PER PERCOLATION RATE .-`��,� q�. .WATER ENCOUNTERED NUMBER OF LEACHING PITS DNE APPROVED . . . . . . . . . .. . . . BOARD OF.HEALTH DATE . . . . . . . . r AGENT OR INSPECTOR 41 L ?.vsFG �Ccs�-s•�Alp1 ��JI i PETITIONER I a , 2 - . e ►n ---OD Cb No. kjaf ic I Fee-- BOARD OF HEALTH DESMOND WELL DRILLING, INO.T O W N OF B A R N S TA B L E 5 RAYBER ROAD,BOX 2783 ORLEANS,MA 02653 (508)240-1000 Zippricat ion,forWell Conotruction Permit Application is hereby made for a permit to Construct (4 Alter ( ), or Repair ( )an individual Well at: 5 Oboe arNe. —m mq' va� — -- 3 S► ®1 o - 003 — — Location — Address Assessors Map and Parcel n �Qe tla, ---- L- A u i 5o _' � Owner Address - -------- ---- ------------- Installer Driller Address Type of Building J Dwelling Other - Type of Building—=-------------- No. of Persons--------- Type of Well—��r1�fc��VG - — Capacity --- Purpose of Well- «t3 !`-"^--------- 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 Compliance has been issued by the Board of Health. Sig --— —-------- -- - datebo -- Application Approved By — �� date Application Disapproved for the following reasons: — date Permit No. ` _ — Issued--- --r`�- - ----------- ---------____.._-------- date BOARD OF HEALTH DESMOND WELL DRILLING, WT O W N OF B A R N S T A B L E 5 RAYBER ROAD,BOX 2783 OR MA 02653 (508) (Certificate Of (Compliance 508)240-1000 THIS IS TO CERTIFY, That the Individual Well Constructed V), Altered ( ), or Repaired ( ) b �S wn off• ilk�� :�lU Installer 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. ----------------Dated---- ---------- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE------.__—_ —__.__. _ Inspector -=-------------------- No. Fee- " ---J ---- -- * ` BOARD OF HEALTH DESMOND R RO, D 13X 7,8, IN�fAAAO2 O W N O F B A R N S ORL NS TABLE M_A 02653` (508)240-1000 Application-for Well CongtructionPermit Application is hereby made for a permit to Construct (J), Alter( ), or Repair ( )an individual Well at: o+�r �.�a n2 --' 571 o I a Oc 3 — - — Location — Address \.'_, Assessors Map and Parcel zon Owner Address 'Installer D!,`l1.�------ ---- Gress ---------•-------- Address Type of Building I . Dwelling Other - Type of Building- No. of Persons-- ------_ T e of Well v �- -.__. YP —.�� Capacity--LC�_^ Purpose of Well-� Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation - The undersigned further agrees not to place the well in operation until a Certificate .of Compliance has been issued by the Board of Health. Sig ed — — —--- --— -- datGate Application Approved By 1 __ —_-_----_ �J b date Application Disapproved for the following reasons: W�®� � � 'I� _— --date ---- Permit No. C}�—/ Issued-- 'L!___--/u------------ ------- date BOARD OF HEALTH DESMOND WELL DRILLING, IN(T O W N OF B A R N S T A B L E 5 RAYBER ROAD,BOX 2783 ORLEANS,MA 02653 �� (508)240-1000 Certificate sate Of Compliance THIS IS TO CERTIFY, That the Individual Well Constructed V), Altered ( ), or Repaired ( ) by Ads ^orb W L\\ j_S iq, s. ----- ------- - -- - --�----- -------- -------- -- Installer j at Lr` i CI --- —--------------- Pr ----- — ---has been installed in accordance with the provisions of the Town of Barnstable Bo and of Health PrivatgtW; l:jP_r,otteection Regulation as described in the application for Well Construction Permit No. -----------_—____Dated----- --------. t THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE -- _ . Inspector BOARD OF HEALTH TOWN OF BARNSTABLE DESMOND WELL DRILLING INC. !� 5 BARBER ROAD,PDX 'well CongtructionPermit ORLEANS,MA 026533 (508)240-1000 No. 4f�---7Z�/ Fee- -- Permission is hereby granted Jes h( __—____--------------------- to Construct (� ), Alter ( ), or Repair ( ) an Individual Well at: No. --5a- P,� 1 A I�Yv\)0N__-4 1 _—_—_-- -- -— ------------------------------------ 1 — street as shown on the application for a Well Construction Permit n_ 4'-� � f./ � i Dated — --- --—-- ---- -------------- --------------.-.. ... Board of Health DATE L�� r . ✓r DESM®ND WEL DRILLING, INC. 5 RAYSER ROAD;,BOX 2783 ORLEANS,MA 02653 (508)240-1000 ' s � 4i rr ri Ae tp �. _ me40, 1 . ! / rl of ZL 177 a r i t _ , \ nib P •� ' � I � I t e,S peJ a lit//GL Zgee 7 y��lCa 4< i �CYiSEb NeV• z I /�8 L �efW_ !• .DEC �' _' � .-CvMr7,q�viD ASS. Ale,Ie- - ,C'•, 1114-77Jb.�iS �i9�/.`1j • b^r /�c�i'�1�/ �� zz"1/46-.L, Commonwealth of Massachusetts W Title 5 Official Inspection Form Ib Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 59 Otter Lane JiJnt 010 ^00F) Property Address Elizabeth Hemeon Owner Owner's Name nformrequired is Cumma uid MA 02637 08/01/2008 required for q every page. Cityrrown State zip Code Date of inspection Inspection results must be submitted-on this form. Inspection forms may,not be altered in any way. s Important: A. General Information When filling out forms on the computer,use t only the tab key 1. Inspector: c i to move your Brad J. White 4 0 cursor-do not p y= use the return Name of Inspector G: -D key. Bluewater ` Company Name � ] Q 350 Main Street c Company Address tv ,.i West Yarmouth MA 02673 Faun Cityrrown State Zip Code (508)775-2800 . Telephone Number License Number B. Certification certify that I have personalty 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 C61 olLo Inspector's g ture Date The syst 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. HemeonT-5.doc•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 15 a Commonwealth of Massachusetts Z Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments M 59 Otter Lane Property Address Elizabeth Hemeon Owner Owner's Name information is q required for Cumma uid MA 02637 08/01/2008 every 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: -�— p System meets pass criteria. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass section need to be replaced or repaired. The.system, upon completion of the replacement or,repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y,.N, ND).in the ❑ for the following statements. If"not determined," please explain. ❑ The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. .ND Explain: . Observation of sewage backup or break out or high static water level in the distribution box due to broken.or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval.of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed HemeonT-5.doc•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 59 Otter Lane Property Address Elizabeth Hemeon Owner Owner's Name information is q required for Cumma uid MA 02637 08/01/2008 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain; ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ND"Explain: C) Further Evaluation is Required by the Board of Health : ❑ Conditions exist which,require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: - Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil.absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and.SAS and the SAS is within 50 feet of a private water supply well. HemeonT-5.doc•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System,Page 3 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 59 Otter Lane Property Address Elizabeth Hemeon Owner Owner's Name information is C uid MA 02637 08/01/2008 umma required for q every page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well"*. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified.laboratory, for coliform bacteria 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 El Discharge or ponding of effluent to the surface of the ground or surface waters ® due to an overloaded or clogged SAS or cesspool El ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool O ® Liquid depth in cesspool is less than 6" below invert.or available volume is less than '/z day flow ` ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. El ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. HemeonT-5.doc•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 59 Otter Lane Property Address Elizabeth Hemeon Owner Owners Name information is 4 required for Cumma uid MA 02637 08/01/2008 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to Ali Systems (cont.): Yes No ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ® Any portion of a cesspool or privy is within 50 feet of a private water supply 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 El ❑ the system is within 200 feet of a tributary to a surface drinking water supply El ❑ 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. HemeonT-5.cloc•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 59 Otter Lane Property Address Elizabeth Hemeon Owner Owner's Name information is q required for Cumma uid MA 02637 08/01/2008 every page. Cityrrown 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? El ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ElWere 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, exelwdiicig the SAS, located on site? Z ❑ 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)] HemeonT-5:doc-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 15 Commonwealth of Massachusetts . W Title 5 Official Inspection F M Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 59 Otter Lane Property Address Elizabeth Hemeon Owner Owner's Name information is q required for Cumma uid MA 02637 08/01/2008 every page. Cityrrown State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): Unknown Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): Unknown 1 Number of current residents: Does residence have a garbage grinder? ❑ Yes Z. No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? Z Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): 07-331 pep o(n- 3i 6-pi) Sump pump? ❑ Yes ® No Current Last date of occupancy: bate Commercial/Industrial Flow Conditions: Type of Establishment: 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 r Water meter readings, if available: Last date of occupancy/use: Date Other(describe): HemeonT-5.doc•03/08 Title_5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 59 Otter Lane Property Address Elizabeth Hemeon Owner Owner's Name information is Cumma uid MA 02637 08/01/2008 required for q every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: Bluewater. Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1,500 gallons How was quantity pumped determined? Sight tube on truck Reason for pumping: Check tanks structural integrity Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ C��) 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): Approximate age of all components, date installed (if known)and source of information: to. System was installed in 1987 per as built plan of septic system Were sewage odors detected when arriving at the site? ❑ Yes ® No HemeonT-5.doc•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8.of 15 L Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 59 Otter Lane Property Address Elizabeth Hemeon Owner Owner's Name information is Cummaquid MA 02637 08/01/2008 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): 46" . Depth below grade: feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): N/A Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Building sewer is in good condition Used camera to check all exterior piping. Septic Tank(locate on site plan): 40" Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No 10'-6"x 5'-8"x 5'-8" Dimensions: 611 Sludge depth: 31" Distance from top of sludge to bottom of outlet tee or baffle 711 Scum thickness Distance from top of scum to top of outlet tee or baffle 7" 16" Distance from bottom of scum to bottom of outlet tee or baffle Measured How were dimensions determined? HemeonT-S.doc•03/OB Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 Commonwealth of Massachusetts 4 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 59 Otter Lane Property Address Elizabeth Hemeon Owner Owner's Name information is q required for Cumma uid MA 02637 08/01/2008 every page. CitylTown 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.): ow Inlet and outlet tees are in good condition. No evidence of leakage in or out of tank. Inlet cover has a risor 12" below grade. Grease Trap (locate on site plan): Depth below grade: 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 Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related:to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of.inspection) (locate on site plan):. Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): HemeonT-5.doc•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 59 Otter Lane Property Address Elizabeth Hemeon Owner Owner's Name information is Cumma uid MA 02637 08/01/2008 required for q every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank(cont.) 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 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.): Distribution box is level. No evidence of solids carryover. Box is 5' below grade. Box_only has one outlet leaving it. Pump Chamber(locate on site plan):. Pumps in working order: _ ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No HemeonT-5.doc•03/08 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 11 of 15 • I Commonwealth of Massachusetts Title 5 Official' Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 59 Otter Lane Property Address Elizabeth Hemeon Owner Owner's Name information is q required for Cumma uid MA 02637 08/01/2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ------so ® leaching pits number: 1 @ 6'x 6' ❑ 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.): W Soil is dry. No signs of hydraulic failure.Vegetation is normal. Pit is 40" below grade but has a visor 24" below grade Bottom of leaching pit is 112" below grade. Pit had 3 from pipe to water. HemeonT-5.doc•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not.for Voluntary Assessments ,M 59 Otter Lane Property Address Elizabeth Hemeon Owner Owner's Name information is q required for Cumma uid MA 02637 08/01/2008 . every page. Cityfrown State Zip Code Date of Inspection D. System Information(cont.) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): HemeonT-5.doc•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 15" Commonwealth of Massachusetts Title 5. Officia1 Ins-pection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 59 Otter Lane Property Address Elizabeth Hemeon Owner Owner's Name information is Cummaguid MA 02637 08/0172008 required for City/Town State Zip Code Date of Inspection every page. D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two pe rmanent reference landmarks or benchmarks. Locate all wells within 100 feet. water su I enters the building. Locate where public w. pp Y �q _ a � 0 Iva- 0 45 0. l 3- 161 -� AL 24' z z' f33- Iq +�� • 33' Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15 HemeonT-5.doc•03108 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments M 59 Otter Lane Property Address Elizabeth Hemeon Owner Owner's Name information is required for Cummaquid MA 02637 08/01/2008 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells 16' + Estimated depth to high ground water: 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: pate ❑ 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) ---W ® Accessed USGS database-explain: ® Well SDW 2521 Zone A/ Level 47.0/Adjustment 1.1 x 12" = 13.2" You must describe how you established the high ground water elevation: Used lazer level to determine elevations. Bottom of leaching pit is at 112". Add the required usgs adjustment of 13.2" brings the total to 125.2". No indication of groundwater @ 16' +with slope off in rear of property. This leaves an additional 66.8"of additional seperation. HemeonT-S.doc•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page.15.of 15 ,t s C up ce � z r5 a D rd LA 4 � JC G U ® . C c� r o Town of Barnstable �OF THE 1p�� yP o� Regulatory Services BARNBTABLE. ; Thomas F. Geiler,Director A,ED �a Public Health Division Thomas McKean,Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 REGARDING SEPTIC INSPECTIONS BY PRIVATE CONTRACTORS DISCLAIMER This septic system inspection report was completed by a private inspector who is certified by the State of Massachusetts, Department of Environmental Protection. Although the Town of Barnstable Health Division received the original or copy of the report; this Division does not warranty the functionality of the septic system in the future nor does this Division agree with any technical observations and interpretations contained within this report. In addition, by receiving this report the Town of Barnstable Health Division does not automatically approve the number of bedrooms listed within this report. The actual number of bedrooms approved at a particular property would be listed on the "Disposal Works. Construction Permit". If you should have any questions regarding this report, please contact the certified Septic System Inspector who conducted.the inspection. QASEPTICTisclaimer Private Septic Inspections.DOC: Massachusetts Department of Environmental Protection Bureau of Resource Protection WELL DRILLER Please specify work performed: Address at well location: New Well l Street Number: _Street Name: 59� t OTTER LANE '1 Please specify well type: `Building Lot#: Assessor's Map#: Irrigation Assessor's Lot#: ZIP Code: Number Of Wells: 1 102637 City/Town: Well Location BARNSTABLE In public right-of-way: GPS • Yes No North: West: 41.70707 70.26623 Subdivision/Property/Description: CUN4MAQUID _ Mailing Address: • click here if same as well location address. Property Owner: Street Number. ---Street Street Name LYNDA BEDARD 59 OTTER LANE City/Town: State: Engineering Firm: C BARNSTABLE--- MASSACHUSETTS ZIP Code: _ 02637 Board of health permit obtained: • Yes • Not Required' Permit Number: Date Issued: 2010012 6/15/2010 • F.�`1.r — «.t 4 XL Page 1 of 1 t Massachusetts Department of Environmental Protection '�— Bureau of Resource Protection—Well Driller Program Well Completion Reports(Geneial) WELL DRILLER - GENERAL WELL FORM DRILLING METHOD Overburden Bedrock Auger Choose Bedrock-- WELL LOG OVERBURDEN LITHOLOGY » From To(ft) Code Color Comment Drop in Extra fast or slow Loss or addition of (ft) drill stem drill rate fluid 0 Silty Sand Brown Yes: Fast Slow` Loss Addition 20F r^ 20 25 Silty Sand Brown Yes. • Fast Slow; Loss Addition —^ 30 Clay Yes; Fast Slow, Loss Addition: Brown 30 45 Sity Sand Brown •4Yes Fast Slow Loss Addition _ 45 57 Fine To Coarse Sand Brown ; Yes; Fast Slow Loss Addition WELL LOG BEDROCK LITHOLOGY Visible Extra From Drop in Extra fast or slow Loss or addition of To(ft) Code Comment Rust- Large (ft) drill stem drill rate fluid Staining Chips Choose Code Yes Fast Slow Loss Addition Yes: Yes ADDITIONAL WELL INFORMATION Developed Yes No Disinfected Yes No Total Well Depth 157 Depth to Bedrock Fracture Surface Seal Type None Enhancement Yes No CASING Is Casing above ground?; From To Type Thickness Diameter Driveshoe 49 Polyvinyl Chloride __ Schedule 40 1 14 SCREEN No Screen From To Type Slot Size Diameter 49 57 Stainless Steel Well Point 0.010 4 WATER-BEARING ZONES DRY WELL' From To Yield(gpm), 19 157 15—-•--- __ PERMANENT PUMP(IF AVAILABLE 2 Wire Constant Speed Pump Description Horsepower Submersible �1 Page 1 of 2 n Massachusetts Department of Environmental Protection 'w Bureau of Resource Protection—Well Driller Program /I. Well Completion Reports(General) Pump Intake Depth ft 50 Nominal Pump Capacity( pm) 20 ' ANNULAR SEAL/RLTER PACK Water From To Material 1 Weight Material 2 Weight(gal) yBatches Method.Of Placement Choose Material Choose Material Choose One �C WELL TEST DATA Time. Time.To Recovery(ft Pumping Date Method Yield(gpm) „= Level (ft ' Pumped BGS) Recover BGS) 6/21/2010 Constant Rate Pump C15 1 00`-y 25 ...._ _ 0:01 19 WATER LEVEL _ Date Measured Static Depth BGS(ft) Flowing Rate(gpm)y 6/30/2010 19 1155 COMMENTS WELL DRILLERS STATEMENT This well was drilled or altered under my direct supervision,according to the applicable rules and regulations,and this report is complete and accurate to the best of my knowledge. Driller ITIAOMNSEDESMONDIII Registration# 764 _ Supervising Driller Signature DESMONDIII,THOMAS Firm DESMOND WELL DRILLIN; Rig Permit# 100 Date Job Complete [6/30/2010 NOTE:Well Completion Reports must be filed by the registered well driller within 30 days of well completion. Page 2 of 2 ENVIROTECII LABORATORIES,INC MA CERT.NO.:M-MA 063 8 Jan Sebastian Drive Unit 12 Sandwich,MA 02563 (508)888-6460 1-800-339-6460. FAX(508)888-6446 Client NameDesmond Well Drilling Location 59 Otter Lane,Cummaquid,MA Address PO Box 2783 Orleans MA 02653 Sample Date 06/22/10 Collected By Envirotech Sample Time 3:30 Sample Type New well Date.Received 06/22/10 Lab Order Number DW-101517 Well Specs NA Location Source Date Collected Time Collected 'orirrnents A 06/22/10 £15.00' Analysis Requested ---Units Recommended Limits Analysis Result Method jDateAnalyzedl Analyzed By "- Total Coliform /100ml 0 0 SM9222B 6/22/2010 MC pH pH units 6 5 8 5 613 SM4500 H B 6/22/2010 LL Specific Conductancen umhos/cm 500 187 EPA 120.1 6/22/2010 LL _.. Nitrite-N mg/L 1.00 <0 004 EPA 300.0 6/22/2010 LL - Nitrate-N mg/L 10.0 1 49 EPA 300.0 6/22/2010 LL --.,_- - .- ------------- - - - _ - - Sodium mg/L 20.0 16.3 EPA 200.7 6/22/2010 MC Total Irona mg/L 0.3 0.03 EPA 200.7 - 6/22/2010 _ MC Manganesen mg/L 0.05 0.086 EPA 200.7 6/22/2010 MC Comments: Manganese is not a health hazard. .pH is below recommended limit and may have corrosive characteristics.' Water meets EPA st4rdsaita for drinking for parameters tested. Date ^ 1 of 1 Attached Page - Limits See BRL-Below Reportable P r non- otable water samples.. ❑Certt:cation is not available or this analyte fo p_ p f • P AsBuilt Page 1 of 1 TOWN OF BARNSTABLE, p LOCATION 0� p—772FL G nw6 SEWAGE # V-&3 VILLAGE ASSESSOR'S MAP LOT 35(-0(0-003 ,INSTALLER'S NAME & PHONE NO. Q r u b`-5 60 SEPTIC TANK CAPACITY ® a LEACHING FACILITY:(type) �/ (size) /p 6 O NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER OBUILDER OR OWNERir/ DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: Z- / 'W 7 VARIANCE GRANTED: Yes No r •. http://issgl2/intranet/propdata/prebuilt.aspx?mappar=351010003&seq=l - 12/24/2015 EDWARD E. KELLEY REG. LAND SURVEYOR CUMMAQUID, MASS. 02637 TEL : (617 ) 362-2266 February 12, 1988 Town of Barnstable Board of Health 367 Main Street Hyannis,Massm 02601 Refs Lot # 3A Otter Lane Barnstable William Me Hemeon, owner On final inspection on August 27, 1987 the as built system , complied with the proposed plan with the exception of the edge of the leach it being 17' from the garage foundation (not a cellar walla The system complies with the Town of Barnstable Health Regulations and Title V. �T N Of oaO / yGw `N Or RASs�I ne.U) o� EDWARD (( C E. 9�C/STEp `9-� IVo. 20100��l Reg, ai Reg. Pr�,o. ��s� 4z ,�purveyor TOWN OF BARNSTABLE e LOCATION/0 p 717i�7r SEWAGE # ?'C� VILLAGE 90,'V--S l AL L L' ASSESSOR'S MAP & LOT 35-(`o]v-003 _INSTALLER'S NAME & PHONE NO.�12 & GC-'i� �ON$ (- 6.0 SEPTIC TANK CAPACITY 00 LEACHING FACILITY:(type) ,/'2/ / (size) /d 6 O NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER ��/�' ��5 `� kn9 DATE PERMIT ISSUED: / l 3 / / DATE COLIPLIANCE ISSUED: ��- V 7 VARIANCE GRANTED: Yes No c 71 il�SESSORS A11AP NO., 'ARC-El. IM _0_1 (2Z_, (503 Fmic.......7.G.'C*'). . .. .................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 35T, -7—c>w ,/ 010 — 003, ........................................OF....... ................... .......I........................................ Appliration for Uhipogal Workii Towitrurtion Frrmit Application is hereby made for a Permit to Construct (L-� or Repair an Individual Sewage Disposal System at: 0171�c &A) Z6 7 ...........................................;11----------------------------------------------------- -------------------------------------- .................................... or 16,ali,-Address Lot .......... ........................ ................ X................................................. Owner jb Address K, /7/,,7ZS7-0 ,--s ................................................................... ....................... .................................................................................................. Installer Address Type of Building Size ......Sq. feet U Dwelling—No. of Bedrooms___..__...... ..........................Expansion Attic Garbage Grinder ( ) P4 Other—Type of Building ---------------_----------- No. of persons...._....................... Showers Cafeteria ( ) Ga Other fixtures ......................... ............................................................................................................................ Design Flow................ .............gallons per person per day. Total daily flow__.___...._a.25,&...._.._.._.._._.___gallons. ..........................__..__....._.._.__gallons ............ 1:4 Septic Tank—Liquid capacitv4�_ gallons Length... Width._-*7-.'6_'... Diameter________________ Depth.-5_"6.w_. Disposal Trench—No. .................... Width...._/.............. Total Length............../..... Total leaching area--------_-_------sq. ft. Seepage Pit No----------/-------- Diameter....Z Z--------- Depth below inlet.....4E_...... Total leaching area..:;5?/nA.-sq. ft. Z Other Distribution box Dosing tank ( ) Percolation Test Results Performed by...._ ....... ........... Date........................................ �4 7— Test Pit No. -----------minutes per inch Depth of Test Pit._Z!1;2........ Depth to ground water----- - ------------ _z 2--2-93" Test Pit No. 2----j5L__._.mmutes per inch Depth of Test Pit--- ... Depth to ground water........................ ............................................................................................................................................................. 0 Description of Soil_..._.-q`-174...... ..... /7-0-4�—Z---/'o", lv-a-i,>. ......... ........ ... ..... .. ...........X------------------------------------------------------------------- 'a ENGMEERVUST-SURERAIJ5�........................ --------------------------*----------------------------------------------------------------------- ................ --------------------------------------------------------------------------------------At!- ..................... NSTIALLATMWAND-CERTIFY- U Nature of Repairs or Alterations—Answer when applita�jg__SyS-TE.M.. S.jNST.ALLED__1N._STR1C,1 7................................. .................................................................................................. ............................I............................ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TA!THE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has bee ' s the --,-d 8f health. ........ ....... ... ............................................. --- ........ / Date .......... 7:� Application Approved B .... ............ ------------------------------------------------------ ---------�44 y I;—ate' Application Disapproved for the following .................. reasons:- ,19-- 4-----------------------------*---------------- ... ..... ................................................I------_------ 1 ...................................... 4/ Date Permit No. ............ Issued . ..................................................... ............................ ...... Date No------------------�� (�l svC�= Fss:............ ........::..... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..................... ..............---------------------------•--•---................. Applira#inn for Disposal Works Tnmftrtinn Vvrrmit Application is hereby made for a Permit to_Construct (✓) or Repair ( ) an Individual Sewage Disposal System at: 0, - 1-L)c t.,I W L:- �-r .^�---r-*-��1 v T ` 3A Location Address or Lot No. /t C.. : ..<�.j:1.�:=4^......-. .: ��-!L r? c?q�`1 ........ .......•....•...------ Owner ? / ,/_ Address W r �� / 5 Installer Address d Type of Building Size Lot 6 .. ' ��'_--:---•Sq. feet 4 aDwelling—No. of Bedrooms............ ...........................Expansion Attic ( ) Garbage Grinder ( ) p, Other—Type of Building ............................ No. -of persons............................ Showers ( ) — Cafeteria ( ) (s, Other fixtures •----••-•-------•-•----•---••---•------ - W Design Flow............... . .........•........•__gallons per person per day. Total daily flow............................................gallons. 1:4 Septic Tank—Liquid capacitye!�s_K. .gallons Length..&. ....... Width'q'_.6.".... Diameter________________ Depth.:................ W Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. x If Seepage Pit No.......... -------- Diameter.... -.4•.......... Depth below inlet....`E......... Total leaching area_:;��G...sq. ft. z Other Distribution box ( ) Dosing tank ( ) '-' Percolation Test Results Performed bY.___G ��l.................. ..1�"G G� ............ Date........................................ aTest Pit No. 1...�.........minutes per inch Depth of Test Pit.A! ........ Depth to ground water.._'.Z-'3--......... Test Pit No. 2...2_ "._minutes per inch Depth of Test Pit. ..........Depth to ground water....... ----------------------------------------------•-----------------•-...................-••-•-•................................................................ D Description of Soil_•••-••5 •'- /7. ti G�.a�/ - Zoo,. rye'L�, _ ........ ----------------------------------------- V C G C_,1►-� `'.! --.ice . -•-•._....•------•--------•-•----•••..................................•----••-------•-------•-------•--•••-•-•••---- W -•-•--------------------------=-----•---••------•-•---••••------------••---•-•-•-••--•-----•..._....---•-----•-------•----•----------•------•--•-------------------•-------•---•---•--•-•----•..._...... UNature"of Repairs or Alterations—Answer when applicable...........................................................................:__.............___. Agreement: The undersigned agrees to install the afor edescribed Individual Sewage Disposal System in accordance with the provisions of TITHE, j of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. - _ > •ed....................................................................................... ................................ . Date Application Approved By............ / Date Application Disapproved for the following reasons:- -- ..------.- ----------------------------------------•---------- .--------- •-•-••......-• ..•. ---------------•••------�-.._....... s.. ...._.. ..-------� -- ---------------------------------- -----� "7 Date ..Permit No:_....-----•=---•--.......--•-=�-------------------• ... Issued:--•-------•--................................=....... .. Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Trr tifiratr of Toutplianrr THfS L-CERTIFY_- at the Individual Se ge Dispo a System_ onstructed (�.or Repaired ( } ' 4v .... Installer ............................................................ at /1...----- �'`v 'n1 '' has been instailed in accordance with the provisions of TiTIE j of The State Sanitary Code _described in the application for Disposal Works Construction Permit No...... .... dated-------_%_._.----------L................... THE ISSUANCE OF THIS CERTIFICATE-SHALL NOT BE�CONSTRUED AS A GUARANTEE THAT YHE SYSTEM WILL FUNCTION SATISFACTORY. DATE........................•-----•-------••-•---.........-••-•---•---...--•--..•--• Inspector........:....................................................................... = THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .OF .I,�._ . .. e�z.-vs -Cl. _ —_, .............. —' FEE.........:........... Dispnoa1 arks (Elonstrurtion rr t Permission is hereby granted...................... ...... ._ ....:..............._._. to Construct (✓'f or Repair ( ) an Individual Sewage Disposal System atN0.. .1...... =^ ............. ............. r J......M t_./. ........................................................... Street as shown on the application for Disposal Works Construction Permit No.F.j'1 ............... Dated..: Board of Health DATE....................................... •••.................................. A14 _ . - FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS �,� ` '`'•yam f�44"� G"'i)`_,�I v"�� TOP OF FOUNDATION CONCRETE COVER CONCRETE COVERS 7,86 ,e o 4' CAST IRON 12"MAX.• 12"MAX. • , OR SCHEDULE 40 4°SCHEDULE 40 PV.C.(ONLY) P.V.C. PIPE� PIPE- MIN. LEACH' PITCH I/4"PER. PITCH I/4"PER.FT. PIT o•� PRECAST N a LEACHING VERT i'0 EL••��/` •• INVERT INVERT o . 6•i PIT OR SEPTIC TANK DIST. . w EQUIV. INVER7 EL.�6.•. . . EL76.GZ. ; >_ . ..�S o.... GAL. INVERT BOX ::� SoU a Op: .,. EL4!.. INVERT -0 �. :►; 3/4"TO IIli' ELF-S`� e.' �� : WASHED '`e , � � ;•� w STONE • 3� WDIA. ---•I �— • DIA-----►-I. 9.8G',� _EZ.r/.oG PROFI LE OF GROUND WATER TABLE SEWAGE DISPOSAL SYSTEM Avow- Ize i�rP�izV.ovs �97�1Lr6}L /,v 7?vL-- NO SCALE •4:-dw B�vNp m 4e-2L�sv v6D w,7;V ce&7hv SahvD. (.SNADSD SOIL LOG WITNESSED BY : BOARD OF HEALTH TEST HOLE I TEST HOLE 2 Gly<rf.G% ZCG- ENGINEER ELEV. . .3a,.c56 . . ELEV. .Z9�39. . . �o DESIGN DATA Sv Soil NUMBER OF BEDROOMS . . . . . . . . . . . . . . CLA-. ee_fi TOTAL ESTIMATED FLOW . . . GALLONS/DAY BOTTOM LEACH I NG AREA ��3•. . SQ.FT. /PIT16',,p /y&D, SIDE LEACHING AREA . . .�BB•5o SQ.FT./ PIT/47/c•P•D, CG173� S/�},va GARBAGE DISPOSAL'.N4^��`�. . .(50% AREA INCREASE) SSA ►N � TOTAL LEACHING AREA SQ.FT az8 wRrb Zzo" &Z./4 a C - - --- -- - ,//.oG -- -- -- - PERCOLATION RATE 71A- 7?-!O . MIN/INCH l�o" GfZ, /0.06 ZZS" EZ./0,3/9 " LEACHING AREA PER PERCOLATION RATE .� �. 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OF ��Ly >fv� E�VA ✓' >k A.' -. �C'EY/Sf?> NOV, Z/ /�8 L KELLEY N �� L i(CE2 c �y L jjl//Ri� I No. 26100 i /✓b rE L*4144777e>A/S a i