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" CERTIFICATE .,OF ANALYSIS
' r M Barnstable County'Health Laboratory,(M-MAF009)
Report Prepared For: Report Dated: M/4/2015
Ted Theodores "_ ,� - _"`
Ordelr No. G1540962 � n
50 Shepherds Way *. k• F
Barnstable, IVIA' 02630 to "'PI Y ..
'x 4=,m
Laboratory 1Q#: 1590962-01 Description Water rDrinkmg Water,* '( �'
Sample#: Sample Location 50 Shepherds Way 8amstable,.M" A Collected: 11/02/2'd15
Collected by: Ted.T. m `+ Received: -11/02/2015
Routine
ITEM RESULT- UNITS: RL' MCL ' METHOD4, ANALYST° TESTED 'NOTE
Nitrate as.Nitrogen j K 0.42.E. 1" Y.mg/L . 0,10 10. EPA 300.0 LAP 11/3/201'5
COpper hID - mg/L^ 0.10', 1.3:, "*SM 3111B LAP 11/4/2015
Iron
# A 0.16
mg/L 0:10 0.3,° "SM 3111B'.Y` LAP 11/4/201.5
pH ` 7.5 ; PH AT 25C °' NA 6 5-8.5 SM 4500-1-1-13 'DCB .11/2/2015
Sodium {ND mg/L " 2 5 20 ° SM 3111 B l' LAP 11/4/2015
Total Coliform . ' Absents y P/A a ^ w 0 0 SM 9223 RG 1 11212 0 1 5
Conductance, x 420 -•umohs/cm 2.0 EPA 120.1` -DCB ' 11./2/2015
,, t
- - -- - r
ve tested aramete s.
rWater sample meets the recommendedThmits for dunking water of all abo p ,_
Attached please find the laboratory certified parameter listt;' "X Approved: By:
s . Lab Director
., _.x
- • � tea' ,� r
`' -s � '' -� i Fyn ,. S �x `. e t' `' • ..
f eqi..
ND=None Detected RL = Reporting Limit MCL.=Mazimumi Contaminant Level,
5-6605;
305 Main Street, PO. Box 427, Barnstable, MA 02630 Ph 508-37 '
CERTIFICATE OF ANALYSIS
Barnstable County Health Laboratory (M-MA009)
Recipient: Matrix: Water-Drinking Water
Ted Theodores.
Sampled: 11/02/2015 11:00
50 Shepherds Way. Received: 11/02/2015 11:40
`
Collection Address: 50 Shepherds Way Barnstable,MA
Barnstable, MA 02630
Sample Location: iT
Order#: G1590962
Description: rkt
Lab ID: 1590962-01 Date Analyzed: .? 11/2/201.5 @ 16:27
Sample#: Analyst: yn
Method: EPA 524.2 Dilution Factor: 1
Comment: 'Water sample meets the recommended-limits for drinking-water of all the°above tested parameters
EPA 524,2 - Volatile Organics by GC/MS
r Result• MCL MDL Result MCL MDL
Parameter ug/L . ug/L ug/L Parameter ug/L ud/L ug/L
Dichlorodifluoromethane ND 0.50 Chloroform 1.2 80 0.50
Chloromethane ND 0.50 cis-1,2-Dichloroethene ND 70 0.50
Vinyl chloride ND. 2.0 0.50 cis-1,3-Dichloropropene ND 0.50
Bromomethane • ND 0.50 Dibromochloromethane ND, 0.50
1,1,1,2-Tetrachloroethane ND` 0.50 Dibromomethane ND 0.50
1,1,1-Trichloroethane ND: 200 0.50 Ethlbenzene . - ND 700 0.510
1,1,2,2-Tetrachloroethane ND, 0.50 Hexachlorobutadiene ND 0.50
1,1,2-Trchloroethane �; ND'�, 5.0 0.5o Isopropylbenzene ND ' 0.50
1,1-Dichloroethane ND 0.50 Methylene chloride ND 5:0 0.50
1,1-Dichloroethene ND 7.0 0.50 Methyl-tert-butyl.ether ND . 0.50
1,1-Dichloropropene NO .0.50 Naphthalene " ND 0.50
1,2,3-Trichlorobenzene iND - 0.50 n-Butylbenzene ND 0.50
1,2,3-Trichloropropane ND 0.50 n-Propylbenzene F" ND 0.50
1,2,4-Trichlorobenzene ND 70 0.50 p-Isopropyltoluene ND 0.50
1,2,4-Td methyl benzene ND 0.50 sec-Butyl benzene ND 0.50
1,2-Dibromo-3-chloropropane ND 0.50 Styrene ND 100 0.50
1,2-Dibromoethane(EDB) ND 0.50 tert-Butylbenzene ND 0.50
1,2-Dichlorobenzene ND 600 0.50 Tetrachloroethene ND 5.0 0.50
1,2-Dichloroethane ND 5.0 '0.50 Toluene ND 1000 0:50
1,2-Dichloropropane ND 0.50 Total xylenes ND 10000 0.50
1,3,5-Trimethylbenzene ND 0.50 trans-1,2-Dichloroethene ND 100 0.50
1,3-Dichlorobenzene ` ND 0.50 trans-1,3-Dichloropropene . ND 0.50
1,3-Dichloropropane ND, 0.50 Trichloroethene ND 5.0 0.50
1,4-DichlorobenzOne ND, 5.0 0.50 Trichlorofluoromethane ND 0.50
2,2-Dichloropropane ND 0.50 Surrogates' , %Recovered QC Limits(%)
2-Chlorotoluene ND` i).50 p_Bromofloorobenzene' 77% 70 1 130
4-Chlorotoluene _ ND, , 0.50 1 2-Dichlorobenzene-d4 83% 70 1 130
Benzene ND
5.
0 0.50
Bromobenzene ND 0.50
Bromochloromethane ND 0.50 „
Bromodichloromethane ND 0.50
Bromoform ND 0.50
Carbon tetrachloride ND 5.0 0.50
Chlorobenzene ND 100 0.50
Chloroethane ND 0.50
r
Approved B
Attached please find the laboratory certified parameter list. (Lab Director)
ND None Detected ` RL Reporting Limit MCL=Maximum�'n�� t�Lev 3195 Main Street, PO. Box 427, Barnstable, MA 02630 `Ph: 508-375-6605 Page i of 1
r,
Ted Theodores
50 Shepherds Way
Bamstable, MA 02630
TOWN Ur
HEALTH DEPT.
July 20, 2001 re: Calves Pasture Lane, Barnstable
DEP File Nos.SE3-3714, 3715
Robert A. Lancaster, Chairman, Conservation Commission
Town of Barnstable Conservation Division RECEIVED
367 Main Street
Hyannis, MA 02601 JUL 0 2001
Dear Mr. Lancaster, TOWN OF BARNSTABLE
HEALTH DEPT.
The 'attached Petition was prepared for delivery to the
Conservation Commission last fall, but was withheld pending re-
scheduling of the Public Hearing to consider the application for
an Order of Conditions on this case.
...We are now formally submitting the signed original document for
the Conservation Commission' s file, along with copies to the
Board of Health and other Town Officials who are, or will be
involved in this matter.
For the many reasons cited in the document, `the more-than-one-
hundred Petitioners wish to re-affirm their most fervent
opposition to. the granting of variances for this project. We
understand that the Applicant's have recently revised their
proposal to one single-family dwelling on the two lots, but that
deviations from the Board of Health' s mandate of June 7, 1989 and
the ,Town' s Environmental Regulations are still necessary for
implementation.
We want to urge the Conservation Commission, upon completion of
its review, to issue a Denial Order of Conditions in this case
and, we are asking the Board of Health to remain firm in its 1989
position.
Sincerely.
CC: Conservation Commission , (6) , Boa-r'd=o-fZHeaat-h(3j
Town Attorney (3) , Planning Board (7)
<tteeodores@mediaone.net> Phone & Fax 508. 362. 3553
PETITIOI
Thi,:undenigned:residents of Scudder Lane,Calves Pasture Lane,and Shepherds
Way,-Barnstable;Massachusetts;;and other interested parties,hereby petition the
Town,of Barnstable Conservation:Commission to deny an:Order:of Conditions
related to the applications of Laurie"A.Warren and Christopher P Kuhn,for-the
proposed constructi' f two single family houses,havingseptic systems xhat would
require substantial wetland setback`wariances,along_with other site modifications at
Lots 38 and 39.Calves Pasture Lane,Barnstable,MA(Assessor's Vla )259),
File Numbers SEX=3714,and W-3715. F
It is.understoodahat the.Conservation Comi ibsion will conduct i second Public
Hearing on.this matter.on October 24,2000
3
The petitioners cite the following criteria,.among others,for these requested actions
1. That-the Sandy.Neck and Barnstable Harbor.ecosystems are extremely"
fragile and already indicate signs of suffering damagefrom:septic pollutants
and.bacteriaj.
2.,•. That these important ecosystems sapport'other marine wildlife.and aquatic f
systems;far;beyond the Barnstable region into Cape`Cod Bay,
3.'; That;the predom"inane soil`type in this area`is clay,and therefore`not optimal
or dependable for leaching and drainage.`_- 4
4 .;That he estabhshment,of stringent-septicsystem regulations by the Town of
Barnstable many years''ago recognized the critical mature of,the wetlands
within the To Ws borders and clearly stated the Towns intention to protect
them:
5 That'Barmtable Ilar6or serves many res dents and non resident&AA a
superb and'pristine area for many outdoor recreational act vihesmich as
swimming,°boating,fishing and she fishing,and must be preserved as such.
b. ;That.Barnstable.Harbor provides mny individuals,and families with income
from.commercial fishing, shell fishing and boating activities;and'also must
1- 4 be preserved as such
7:', That the approval•of any wetland setbackvariances,and especially of tthe
magnitude regnested*the above applicants;would constitute an; �. .
unfortunate and potentially dangerous precedent.
8. 77
Throughout the,lengthy history'of_this property;the.petitioners have relied
upon the Board of•Health'9 letter of Jii47, 1989 which outlines specific
restrctions`regarduig these.two lots.and among other.things,states,
variances from Title 5,Minimum.Requirement for the_Subsurfa-e Disposal
of Sanitary Sewage or the Town of Barnstable Health:Regulations whichever
is snore stringent,will not be granted on any lot in this subdivision...
•
y
CALVES PASTURE LANE-BACKGROUND AND CURRENT SITUA77ON
T g two subject lots on Calves Pasture Lane,which adjoin the salt marsh and contain wetland and
watercourses,are part of a Definitive Subdivision Plan filed by Harry&Susan Jilson,dated
January 31, 1989. The subdivision plea was reviewed and approved by the Barnstable Planniing
Board and Board of Health with certain rccorrmundations and conditions m July of 1989.
On June 7, 1989,the Board of Health recommended,among other items:
I".. the developer must provide public water to each lot..."
2"..-the developer shall have recorded on the deed that variances frm Title 5.:.or Town of
Barnstable Health Regulations whichever is more stringent,wiff not be grid on any lot..."
3"..-the applicant must:receive an Order of Conditions f-om the Conservation Commission...
4"...each smage disposal leaching hrcility be located most distant from wetlands to reduce
eutrophication caused by phosphorous and other nutrients."
On July 11, 1989,the Planning Board approved the subdivision plan subject to,"...all the
requirerrnents of the Board of Health...",among other specific conditions.
On Decernber 14, 1999 the applicants requested septic sy n setback variances from local Board
of Health Regulations. The requested variances are in excess of 30 feet tbott ty locating the
system approximately 50 fed from leaching facilities to bordering vegetated wedanrd(100 fed is
required by the Regulations). The applicants also intend to insW private well water systems.
The property;cos foreclosed in a mortgage default and sold at aucuou on August 9,2000. Terms
of the We were$20,000 cash plus assumption of unpaid taxes and other liens.
A Public Hearing was}Held by the Conservation Commission on August 23,2000 to review the
applicants'.request for an Choler of Conditions. The applicants'attorney stated thaf they felt the
Board of Health has already granted the permits through a default of their denial notice,avid thu.
an appeal has been filed in Superior Court. The Conservation Commission agreed to a
continuance until October 24, 2000,at which time the applicant will be given the opportunity to
demonstrate that the propose}septic systems would function properly with the variances.
At the hearing,the applicants also indicated a need to"..,extend culverts carrying runoffnmder
Calves Pasture Lame..."which in the opinion of the Coro emission,would require the filling of
wzatcrcourses,an act not allowed under Title S.
Attorney Charles M. Sabatt represents a group of concerned neighbors and has communicated
directly with appropriate town authorities and pry the group's position at public karnags.
1U neighborhood group feels that,since there is the paterdal for significant damage to
Barnstable Harbor water duality,the issue should-involve a broader segment of the cormnunity,
The group therefore suggests that interested parties sign the accot vinag Pedt hM attend the
Consmration Commission Public Hearing at 6 30PM one er 24, 200 voice oppostiorr
to the graining of septic system variance$on Barnstuble's ant.
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BARNSTABLE FIRE DEPARTMENT
324 Main Street treet—P.O.Box 94
. � a>t
Barnstable,Massachusetts 02630
508-362-3312
FAX: 508-362-8444
WILLIAM A.JONES, III - HAROLD M.SIEGEL
FIRE CHIEF DEPUTY FIRE CHIEF
March 10, 2000
UNDERGROUND STORAGE TANK REPORT
Property Address: 50 Shepha'rd Way,Barnstable
Property Owner: Robert Sverid
Removal Date:March 10;2004
COMMENT: Witnessed the removal of a 500 gallon U.G.S. Tank used for the storage of No.
2 fuel oil from this location. The tank appeared to be OK, with no signs of leaking. The
excavation Oa appeared to be clean with no residual odors of fuel or discoloration. The
contractor as advised to remov the tank from this location and to backfill the site.
Harold M. Siegel
Deputy Fire C
i
t
1.:-`� � Page: 1
CERTIFICATE OF ANALYSIS
Barnstable County Health Laboratory
Re port Pre aced For: Report Dated: 02/04/2000
A p
Order Number: G0004799
Ted Theodores
50 Shepherds
he herds
P Way
Barnstable, MA 02630
Laboratory ID#: 0004799-01 Description: 'Water-Drinking Water
Sample#: 04799 Sampling Location: 50 Shepherds Way,Barnstable Collected: 01/18/2000
Collected by: Robert Sverid 20950-F Lot 27 Received: . 01/18/2000
Routine
ITEM RESULT UNITS MCL Method# Tested.
LAB: IC Lab
Nitrates 0.4 mg/L 10. EPA 300.0 01/18/2000
LAB: Metals
Copper 0.4 mom" 1.3 SM 31118 02/03/2000
Iron 0.2 mg/L. 0.3 SM 3111B. 02/03/2000
Sodium 19.2 mgfL 20 SM 311113 02/03/2000 -
LAB: Microbiology
Total Coliform Absent T/a Absent P/A 01/18/2000
LAB: Physical Chemistry
Conductance 215 umohs/cm EPA 120.1 01/18/2000
PH
(•6 pH-units EPA 150.1 01/18/2000
-
Note: Water sample meets the recommended limits for drinking water of all above tested parameters.
Approved BV: j ram....,---
(Lab Director)/p, .
�'`%
Superior Court House, PO.Box 427, Barnstable, MA 02630 Phiv=508-3F75Y-'6605
NALYSIS Page:
CERTIFICATE OF A ,
Barnstable County Health`Laboratory
_
Report Prepared For: Report.Dated: 02/04/2000
Order Number: G0004828
Ron Ferro
30 Old Salt Lane
YarmouthpoM MA 02675
Laboratory ID#: 0004828-01 Description:. Water-Drinldng Water
Sample#: 04828 Sampling Location: 109.Woodland Rd, Hyannis Collected: 01/20/2000
I Map :M2& farce 69 P 01 Received: 01/20/2000 6
Collected by: .Ronald Ferro .Routine
ITEM RESULT UNITS MCL Method# Tested^
LAB: IC Lab
Nitrates 1.5 mg/L 10 EPA 300.0 O V20/2000
LAB:Metals
Copper <0.1 mg/L 1.3 SM 3 i 11B 02/03/2060
Iron 0.5 . mg/L. 0.3 SM 3111E 02/03/2000
Sodium 39 mg/L 20 sM 3111s 02/03/2000
LAB Microbiology
.Total Coliform. Absent P/A. Absent P/A 01/20/2000
LAB: Physical Chemistry
Conductance 319 umohs/cm, EPAi20.1 01/20/2000
pH 7.2 pH-units EPA 150:1 01/20/2000
Note: Based on the results of the parameters tested,thew ater has high levels of sodium.Persons on low sodium diet should
consult their doctor.
Approved By:2 _.
(Lab Director)
1, k
Superior Court House, PO.Boz 427, Barnstable, MA 02630 Ph: 508-375-6605
Page: 1
CERTIFICATE F
.. ® ANALYSIS
Barnstable County Health Laboratory
Report Prepared For: Report Hated: 02/04/2000
Order Number: G0004824
Carol Lebel-O'Brien
132 Old Route 132
Hyannis, MA 02601
Laboratory ID#: 0004824-01 Description: . Water-Drinldng Water
Sample#• 04824 Sampling Location: 132 Old Route 132,Hyannis Collected: 01/20/2000
Collected by: Carol Lebel-O Received: 01/20/2000
Routine
ITEM RESULT `UNITS MCL Method# Tested
LAB: IC Lab
Nitrates - <0.1` mg/L 10 EPA 300.0: 01/20/2000
LAB:Metals
Copper 0.1 mgrL 1.3 sM 3111E-- 02/03/2000
Iron 0.2 mg/L . 0:3 sM 3111E 02/03/2000
Sodium 5.5_ mg/L 20 SM 311113 02/03/2000
LAB:Microbiology
Total Coliform Absent I P/A Absent P/a 01/20/2000
LAB: Physical Chemistry,
Conductance .95 umobs/cm EPA 120.1 01i20/2000
pH 5.4. pH-units' EPA 150.1 '01/20/2000
Note: Water sample meets the recommended limits for drinking water of all above tested parameters.
Approved By:
(Lab Director)
t -
st
Superior Court House, PO.Box 427, Barnstable, MA 02630 Ph: 508-375-6605
J /v`
�� - iJJiS
TROY WILLIAMS
SEPTIC INSPECTIONS
Certified by MA Department of Environmental Protection (508) 385-1300
19 Hummel Drive
South Dennis, MA 02660
COMMONWEALTH OF MASSACHUSETTS
�r
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAItFtS ,�Vf�
`*
DEPARTMENT OF ENVIRONMENTAL PROTEC,/TION 0 J 4,
ONE WINTER STREET, BOSTON MA 02108 (617)292-5500 r
N
)'Oho"� 8 2000
y ,'7ip4,S t48gRUDY COXE
Secre4�ary
ARGEO PAUL CELLUCCI DAVID B`STRUHS
Governor ,,R_ �Go unissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: SO S ti c P ¢r cl S (<J ca y .
Name of owner R p�c r �- �S v G r ; d
6 i�r n y -tr-6)c
Address of Owner'_ S U J �,t;o 1,�✓�s G-)CA
Date of on: 1 �! /00 y
truppeti Name of Inspector:(Please Pant) Troy Williams k3r,r h s4r�I-/v AA o.. 0.Z 6 3 C)
I am a DEP approved system inspector pursuant to Section'15.340 of Title 5(310 CMR 15.000)
Company Name: Troy Williams Se tip c Inspections
Mailing Address: 19 Hummei Drive, So- Dennis, MA 02660 {
Telephone Number: (508) 385-1300
CERTIFICATION STATEMENT —a
1 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 inspection. The Inspection was performed based on my training and experience In the proper function and
maintenance of on-site sewage disposal systems. The system:
Passes
Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
_ Fail/
4upector's Signature: Date:
The System Inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within thirty(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 Department of Environmental Protection. The original should be sent to the
system owner and copies sent to the buyer,if applicable,and the approving authority.
NOTES AND COMMENTS
Although system meets the minimum requirements set forth by the Massachusetts Department of
Environmental Protection,certification is not to be construed as a guarantee of future working condition
of system,piping or components. This inspection represents the conditions of the system on the Date of
Inspection noted above.
revised 9 2 98 pate I or il
t
SUBSURFACE SEWAGE DISPOSAL'SYSTEM INSPECTION FORM
PART'A
CERTIFICATION(con6nt ed)
Owner:Prop"A 50 Shepherds Way,Barnstable,MA
Date of kis4 ti«,: Robert&Patricia Sverid '
January 11, 2000
INSPECTION SUMMARY: Check A, B, C, or D:
A. SYSTEM PASSES:
V1 have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure
criteria not evaluated are indicated below.
COMMENTS:
B. SYSTEM CONDITIONALLY PASSES: 1\1119
One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system,upon
completion of the replacement or repair, as approved by the Board of Health, will pass.
Indicate yes;no,or not determined(Y,N,or ND). Describe basis of determination In all instances. If"not determined",explain why not.
The septic tank is metal,unless the owner or operator has provided the system
P y m inspector with a copy of a Certificate of
Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or
the septic tank, whether or not metal,is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank
failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as
approved by the Board of Health.
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)
or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of
Health).
broken s i e
P P l l are replaced
obstruction is removed
distribution box is levelled or replaced
The system required pumping more than four 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
� e
t n
revised 9/2/98 Pege2of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Prop"Address: 50 Shepherds Way, Barnstable, MA
Owner: Robert&Patricia Sverid
Date of Inspection: January 11, 2000
C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: / 119
Conditions exist which require further evaluation by the Board of Health in order to.determine if the system is failing to protect the
public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES W ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM
IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of 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 AND SAFETY AND THE 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.soil absorption system and the SAS is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the
well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less
than 5 ppm. Method used to determine distance (approximation not valid).
3) OTHER
revised 9/2/98 Page 3ofII
f
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PARt A
CERTIFICATION (continued)
50 Shepherds Way,Barnstable, MA
Property Andress: Robert&Patricia Sverid '
Owner: January 11, 2000
Date oflnspection:
D. SYSTEM FAILS:
You must indicate either "Yes' or "No" to each of the following:
I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this
determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure.
Yes No
Backup of sewage into facility or system component due-to an 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 1/2 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 Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
Any portion of a cesspool or privy is within a Zone I of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is less-than 100 feet but greater than 60 feet from a private water supply well with no
acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E. LARGE SYSTEM FAILS: 1,1113
You must indicate either "Yes"or"No" to each of the following:
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public
health and safety and the environment because one or more of the following conditions exist:
Yes 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)
The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional.
office of the Department for further information..
revised 9/2/98 Page 4ofII
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
N .
Property Address: 50 Shepherds Way,Barnstable,MA `
Owner: Robert&Patricia Sverid p
Date of Inspection: January 11, 2000
Check if the following have been done: You.must indicate either "Yes" or "No" es.to'each of the following:
Yes No
No
iC Pumping information •_ p g ton was provided b the owner Y occu a p nt,orBoardof Health.
.Y None of the r Y_ e co
components have mP ' um p ped�forat least two weeks and-the system-has been•receiving•rrormat flow
rates during that period. Large volumes of water have not been introduced into the system recently or as part of this
/ inspection.
As built plans have been obtained and examined. Note if they are not available with N/A.
The facility or dwelling was inspected for signs of sewage back-up. y
_ The system does not receive non-sanitary or industrial waste flow.`
!C ;_ The site was inspected for signs of breakout.
.JL/ _ All system components, excluding the Soil Absorption System, have.been located on the site.
The septic tank manholes were uncovered,opened, and the interior of the septic tank was inspected for condition of baffles
or tees, material of construction,dimensions,depth of liquid, depth of sludge, depth of scum.
/ The size and location of the Soil Absorption System on the site has been determined based on:
v _ Existing information. For example, Plan at B.O.H.
Determined in the field(if any of the3 failure criteria related to Part C'is at assue a
(15.302(3)(b)) PProximation of distance is unacceptable]
The facility owner(and occupants,if different from owner) were.provided with information on the.
p pr
oper maintananceof
Subsurface Disposal Systems.
- y -
� _ ,e a 4:�•. ' �� t4e .�. .� /
revised 9/2/9t Page soru
SUIISURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM "
PARt C
SYSTEM INFORMATION
Property Address:
Owner: 50 Shepherds Way,Barnstable,MA
Date of Inspection: Robert&Patricia Sverid
January 11, 2000 +
FLOW CONDITIONSRESIDENTIAL: ,
Design flow: / /(U -g,p,d./bedroom.
Number of bedrooms(design): Number of bedrooms(actual): 3
Total DESIGN flow 3 3 a
Number of current residents: 02
Garbage grinder(yes or no):J�ES
Laundry(separate system) (yes or no):/VO: If yes, separate inspection required
Laundry system inspected (yes or no) `
Seasonal use(yes or no):,/O
Water meter readings,if available(last two year's usage(gpd): d e'. l.Jc_.1 I
Sump Pump(yes or no): No
Last date of occupancy: d 4� .,P;e J.
COMMERCMIANDUSTRIAL:
Type of establishment:
Design flow:- apd (Based on 19.203)
Basis of design flow
Grease trap present:(yes or no)_
industrial Waste Holding Tank present:(yes or no)—
Non-sanitary waste discharged to the Title 5 system: (yes or no)
Wat
er meter readings,s,if available:
Last date of occupancy:
OTHER:(Describe)
Last date of occupancy:_
i ' "
GENERAL INFORMATION
PUMPING RECORDS and source of information:
19—s ..A o.nat �� s 1 .� t A 2
System pum ed as part of inspection:(yes or no) Al-
If yes,volume pumped: gallons
Reason for pumping:
TYPE SYSTEM j
Septic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool ,
Privy
Shared system(yes or no) (if yes,attach previous inspection records,if any)
I/A Technology etc.Attach copy of up to date operation and maintenance contract
Tight Tank Copy of DEP Approval
Other
APPROXIMATE AGE of all components,date installed(if known)and source of information: Q•r cw
1 97?. b�,r ► 4-
Sewage odors detected when arriving at the site:(yes or no) /Vo
revised 9/2/98 Page 6ofII
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(co(rtinued)
Property Address:
ovmer: 50 Shepherds Way,Barnstable,MA,
Date of Inspection: Robert&Patricia Sverid
January 11, 2000 +
BUILDING SEWER:
(Locate on site plan)
Depth below grade:
Material of construction:_cast iron V40 PVC_other(explain)
Distance from private water supply well or suction line A1119
Diameter Ll"
Comments:(condition of joints, venting, evidence of leakage,etc.)
� 1H<s uc,✓� fov . J� c.�cor � � 4%, C
SEPTIC TANK:
(locate on site plan)
Depth beloty grade: �
Material of construction: V Concrete_metal_Fiberglass _Polyethylene_other(explain)
If tank is metal,list age Is.age confirmed by Certificate of Compliance_(Yes/No)
Dimensions: S- �X % '2C" 6 DUD 9 c,//o h TGK K
Sludge depth: y
Distance from top of sludge to bottom of outlet tee or baffle: 02/c/
Scum thickness: 3
Distance from top of scum to top of outlet tee or baffle: 6 ,,
Distance from bottom of scum to bottom of o "utlet tee or baffler
How dimensions were determined: Pi'ih lvt
.Comments:
(recommendation for pumpin condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structureHntegrity,
evionce of leakage,etc.)
.�..J A/a P toc t 1 h y. !- r -i^ci�sv.-,a 1
11 c
'�
-✓-�. ti L� 1M J 1 e-
L O ✓fit I+n c M G-(t
GREASE TRAP:�1/
(locate on site plan)
Depth below grade:_
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:
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage,etc.)
revised 9/2/98 Page 7ofII
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PARt C
SYSTEM INFORMATION(continued)
Property Address:
Owner: 50 Shepherds Way,Barnstable, MA
Date of Inspection: Robert&Patricia Sverid
January 11, 2000
TIGHT OR HOLDING TANK:N/A (Tank must be pumped prior to, or 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/day
Alarm present
Alarm level: Alarm in working order:Yes_ No_
Date of previous pumping:
Comments!'
(condition'df inlet tee, condition of alarm and float switches,etc.)
DISTRIBUTION BOX:_Vl
(locate on site plan)
Depth of liquid level above outlet invert: L ✓� I
Comments:
(note-if level and distribution is equal,evidences of solids carryover, evidence of leakage into or out of box;etc.) t7tz•
c�cc.c � c.✓ �i o e'u I � � �,�
/u5� .1 ow. �/•�..«f "L.ro� CI- So u .. / H ✓i dam.,. a< of /ocfic.,j�y
PUMP CHAMBER:_P/,9
(locate on site plan)
Pumps in working order:(Yes or No)
Alarms in working order(Yes or No)
Comments:
(note condition of pump chamber,condition of pumps and appurtenances,etc.)
revised 9/2/98 Page 8of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PAItT C
SYSTEM INFORMATION(continued) -
Property Address:
Owner: 50 Shepherds Way,Barnstable,MA
Date of Irmpection: Robert&Patricia Sverid
January 11, 2000 +
SOIL ABSORPTION SYSTEM(SAS):,--V-/
"(locate on site plan, if possible; excavation not required,location may be approximated by non-intrusive methods)'
If not located,explain:
Type:
leaching pits, number: 00,r ,to X C L c c_
leaching chambers,number._
leaching galleries,number:_
leaching trenches,number,length:
leaching fields,number, dimensions:
overflow cesspool,number._
Alternative system:
Name of Technology:
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding, damp soil,condition of vegetation, etc.)
5 .
CESSPOOLS:L1(�r7 l
(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(cesspool must be pumped as part of inspection)
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:
- sca
Comments:
(note condition on ofso I,signs of hydraulic'failur
e. level of
ponding, condi
tion on'of vegetation. etc.) -
]revised 9/2/98 Page 9oru
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owner: 50 Shepherds Way,Barnstable,MA
Date of Inspection: Robert&Patricia Sverid I
January 11,2000a
I
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reference landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)-I"
Fw +, .
Cs 9
- j
�oUU al�oti
5 , y1 y8 31
6
33'
p-)3ox
xt
�� 2 S 4t .
revised 9/2/98 Page 10of II
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address` 50 Shepherds Way,Barnstable MA
Owner:
Date of Inspection: Robert&Patricia Sverid
January 11, 2000
NRCS Report name
Soil Type_
Typical depth to groundwater
USGS Date website visited
Observation Wells checked
Groundwater depth: Shallow Moderate Deep
SITE EXAM Slope I/
Surface water
Check Cellar
Shallow wells
Estimated Depth to Groundwater'2&Feet
Please indicate all the methods used to determine High Groundwater Elevation:
/Obtained from Design Plans on record
Observed Site iAbutting property, observation hole, basement sump etc.)
Determined from local conditions
Checked with local Board of health
Checked FEMA Maps
Checked pumping records Y
Checked local excavators,installers
V/ Used USGS Data
Describe how you established
l!the
CHigh Groundwater/Elevation. (Must be completed)
(✓ V ✓ {�'�LIp f S,1 6 4✓ �j✓o.i h�1 Li 0.�'Gr 1 h N LfK A c� ✓M, h .rw J ,.�. r
Ll
Wt11�l Oh �IF7✓bP� ♦ P/ . I 0 ' H,.Lc 0. /{30 �uLc'fc.`CA 04
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H v o c ak A c.✓1
O�
revised 9/2/98 Pav 11 or 11
i-
TOWN OF BARNSTABLE
LOCATION LJ1 SEWAG
VILLAGE NSrp3Li- ASSESSOR'S MAP & LOT ®!_�
INSTALLER'S NAME & PHONE NO.
I
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) zODU 12 ' (size) 0�
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER ��(�t�� �UE�� i P
DATE PERMIT ISSUED:
DATE COZIPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
vaov�F�i
D aox
L
c ,Coo
1 7L-
J
sv�d
No..... l �� _
. Fes$."..........................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEAL H
n.. - .OF....... �...... ...... .. ..........................
Appliration -fur Uiiipoiitt1 Worko Tomitrurtion Vane t
Application is hereby'made for a Permit to Construct ( 4 or Repair ( ) an Individual Sewage Disposal.
System at: Locatif•A dress r/�r� or Lot NN..................f.4246vv
•• -r --`-"`1 0- W._ F=� f_C!s _. .�L ._d Q!__14� / e. .
Owner /7ddr�es�s
W ........... 4
C�G /s 1.� '/s!�`'/.-ll!wcwf.:
Installer Address
Type of Building Size feet
U Dwelling—No. of Bedrooms....j..........................._...._Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building ____________________________ No. of persons....__-----_-__--_---------- Showers ( ) — Cafeteria ( )
G4 Other fixtures -----------
Q - - ------------------------------------------------------------------------------------------------------
Design Flow........... g. p p p y. y gallons.
W _________________________ Mons per erson per day. Total daily flow
Septic Tank—Liquid capacity_/S4,n-_gallons Length---------------- Width.----.._..__--_.Diameter_----.-------- Deptli_..............
x Disposal Trench—No_____________________ Width-------------------- Total Length-------------------- Total leaching area-.___._.:- .t-l�q� ft.
Seepage Pit No.__.__�......... Diameter------ Depth below in et_....C9_......__.. Total leaching area--.�_C---'---sq. ft.
z Other Distribution box ( ) Dosing tan ( )
C/�
~' Percolation Test Results Performed b � _ .�.�e... '-----_--____ Date----------------------------------------
a Test Pit No. 1----------------minutes per inch Depth of "Pest Pit.................... Depth to ground water......._.___...-__.____-
44 Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water-..--:---__-----.---._..
P4 ---- . F _ -------------•-------•---...
n
Description Soil-- --------Q.-..11. "...-- <-... { w p
W - -
x
U Nature of Repairs or Alterations—Answer when applicable-------------------------- ._._.__..�•-�_$-..�:,_.._____.._.___.
---------------------------------------------------------------------------------------------------------- --------------------------------------------------------------------------------------------
Agreement:
The undersigned-agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI 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.
Si1 d.- ----------------------------------------- --- ---11-----
Application Approved B r ,Z�'te T
-- -- - -- - - - -
4
Application Disapproved for the following reasons:......................__..._.___.._.........___._.___......._.._._...._..---------•---------nace.......------.
---------------------------------------------- -----------.......................................-.................................................... -------------------------_-----------------------
Date
PermitNo......................................................... Issued........................................................
Date
,_—--- ------------- -----------------------------
No.........1.7 .... ..............................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD F H A
H
sr
.........OF...... . ..... ................
Apli iratiun -for 13i�ipnlqa1 Workii Tomitrurtinn Vrrutft
Application is hereby.made for a Permit to Construct (—) or Repair ( ) an Individual Sewage"Disposal
System at:
j Locat' n-Addre . r Lot "o.
l�_________________---
_ f...YA l6_X_._._______.-_.'�j:___________._......___... ........... :'Sf_____--- We 1.Y.:._ __ __________________.__.____
�- r ry A
I IJOG
nstaller Add --ress
UType of Building Size Lot_: _. ._.J. �-------Sq. feet
Dwelling—No. of Bedrooms..____ ________________________________Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building ____---_--._' a g _______________ No. of persons---------'_,______.___..:... Showers ( ) — Cafeteria ( )
dOther-fixtures ---------------------------------------------------------------------------------------------._...::................................................
W Design Flow.......... b__________________s__._._gallons per person per day. Total daily flow----- _.........._., ...._........gallons.
WSeptic T,.nk—Liquid capacity/SA gallons Length................ Width.-------.------- Diameter_-.____-.._.-___ Depth................
x Disposal Trench—No. ..;:2 ............. Width-----&------------ Total Length......_f�_..___-___.- Total leaching area.---_-.-_---._.____.sq. ft.
Seepage Pit No--------------------- Diameter.................... Depth below inlet.... .... ._. Tot 1�lea ping•tre;�.__T._^__
Z Other Distribution box ( ) Dosing tanl ) " +� lI
`~ Percolation Test Results Performed by----- ".. 'La _. '+...._...._. Date------------- --------------_-----. .
,.-a Test Pit No..:4 ...............lelinutes per inch Depth of "hest Pit-------------------- Depth'to ground water__.-.__-.__.___._.....
f� Test Pit No'2................minutes per inch Depth of Test Pit.................... Depth to ground water............
-------------------
Description of Soil `- _.(• � !/., j. .
------------ ---- ---------_ - ---- ..................... .......... ---- -- ----- ------- --------------------------
U Nature+of Repairs or Alterations—Answer when applicable._.__--__-.-.-,.____---------------------:_-_.-_----: ____--.--.------_.- ..........
- . ---.
--------------------------
Agreement: a4
j The undersigned agrees to install the, aforedescribed Individual Sewage Disposal System.in accordance.with
1the provisions of Article.XI 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.' ,
r p
`k { Sign "'` --------- --------------------- ---
�` / 1.7
Date
Applicatio°i} Approved BY ---- ..::
Application Disapproved for tfz.e following reasons: `. . ..-.: ._ c. :........................... . .... . .........
.....- ...................------------------•------ ------------------- ------•---•--•---•---••----------•--------•--•---------- ----------••----
Date •=,:
•...........
-.Permit No =.--------- -- - --_r......_. Issued--------------------- ----------•-=---=-'--=---•-------
t ¢ Date
+ E COMMONWEALTH OF MASSACHUSETTS
BOAR,D .OF HEALTH
j
M
1 ....OF.........
.................................................
O ifiratr of I mphanrr
THIS IS TO CERTIFY, That theIndividual Sewage Disposal System constructed ( Jor Repaired ( )
by y ................
�- stal
at.................................................
r -J�
has been installed in accordance with the provision f 1 XI of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No____....._------I_--e......__._.. dated..-._ -.,2. _:-_.7.?____..__.___
THE,-ISSUANCE :OF THIS (CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEIdA WILL FUNCTI0 SATISFACTORY.
DATE-= -- 2 •..... Inspector ..��. ......._l. ;
THE. COMMONWEALTH OF MASSACHUSETTS
.fly. BOARD OF HEALTH
No.........................
FEE ........
Ui;paii l Norkii T11"nnfittttrtioll famit
"
miss
io i hereby granted"___________________________________to Const c Sew os System
Street
as shown on the application for Disposal Works ConstructioAn �
N ____ _-_ Dated�r,d 1' 7/� .............
--
---- ...........-----
Board of 7n,
DATE.._ .. � �- ,. ]/
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS -
EKE m�•. � � -
s�
d 7-
- I
G ,r
V Fig GA/ Pii i
Afla/.
h
M
J '
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C E R T I F I E D PLOT PLAN
LOCATI 0 Nc -SjiS�C✓Y7 S�/t�wv Eo✓
S C A L E: i' 6C�' D A T E:
R E F E R E N C E'
D A'T E
<�. ''
1 HE.RE0Y C E R T I FY THAT THE BUI L DINC EG. LAND SUR �fYOR
SHOWN ON THIS PLAN IS LOCATEb ON
THE GROUND AS SHOWN HEREON AND
T ,J.iS(•.
THAT IT CONFORM TO THE
ZONING GY - LAWS OF THE . TOWN OF
CONSTRUCTED . ' r" ~V.
C M S ASSOCIATES, INC . 4�
REGISTERED ENGINEERS a LAND SURVEYORS
MID -CAPE OFFICE BUILDING - 1 265 ROUTE 28
7TSZ SOUTH YARN O UTFi, M ASS. 02664
TOWN OF BARNSTABLE - UNDERGROUND FUEL AND CHEMICAL STORAGE REGISTRATION
MAP NO. PARCEL NO. �b} t
ADDRESS OF TANK VILLAGE:
Numb�r
MAILING ADDRESS ( IF DIFFERENT FROM-ABOVE) : t'
OWNER NAME: f �h � � PHONE':
'INSTALLATION DATE: 22 BY:
INSTALLER ADDRESS: """ `"� -CERT.NO. '
/t"f� ► /% ! / Vic.
STANK LOCATION:
r ,,s (DGOQRc-S r04 TAN/K LOQAT 2 ON W 2 TFI RQOPQCT TO OU 2 LD 2 NO)
t� CAPACITY TYPE OF TANK AGE /� YRS. FUEL/CHEMICAL
TESTING CERTIFICATION [ ] PASS [ ] FAIL DATE i
s
LEAK DETECTION C ] CHECK IF N/A TYPE/BRAND
YES V O
ZONE OF CONTRIBUTION .] . [ ] NO'v DATE TO BE REMOVED C x
FIRE DEPT. PERMIT ISSUED [ ] YES` C ] NO DATE
CONSERVATION [ ] CHECK IF N/A DATE /
BOARD OF HEALTH TAG NO.[ ] DATE
PLEASE PROVIDE A"SKETCH SHOWING THE TANK LOCATION ON THE BACK OF THIS CARD
f�izv�r
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