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HomeMy WebLinkAbout0315 STONEY POINT ROAD - Health 11 • CERTIFICATE OF ANALYSIS Barnstable County Health Laboratory (M-MA009) Recipient: Sally Desmond Order No.: G18104698 Desmond Well Drilling Report Dated: 02/02/2018 P 0 Box 2783 Submitter: Well Driller Orleans, MA 02553 Description: 2 Day rush-RE Kit-315 Stoney Point Rd. _..............................................-- Laboratory ID#: 18104698-01 Matrix: Water-Drinking Water Sample#: Sampled: 02/01/2018 14:15 By: DWD Collection Address: 315 Stoney Point RD Cummaquid Received: 02/01/2018 15:07 By PalmerP Sample Location: Turn Around: 48 Hr Rush Routine M ITEM RESULT UNITS RL MCL . METHOD# ANALYST TESTED TIME Nitrate as Nitrogen 0.64 mg/L .0.10 10 EPA 300.0 LAP . 02/02/2018 14:43 Iron ND mg/L 0.10 0.3 SM 3111E LAP 02/02/2018 15:27 Manganese--------- - 0.088 mg/L 0.025 0.050 SM 3111B LAP 02/02/2018 15:28 pH 6.6 PH AT 25C NA 6.5-8.5 SM 4500-1-1-13 DCB 02/01/2018 10:44 Sodium_ =-- - — _ 24'� mg/L 2.5 20 SM 31l 1 B LAP 02/02/2018 15:28 Total Coliform Absent P/A 0 0 SM 9223 RG 02/01/2018 16:15 Conductance 230 umohs/cm 2.0 SM 2510E DCB 02/01/2018 10:44 Sodium level is above the maxium contaminant level, Those on a low sodium diet may wish to consult a physician. Attached please find the laboratory certified parameter list. t` Approved B (Lab Director) ND=None Detected RL = Reporting Limit MCL=Maximum Contaminant Level 3195 Main Street, PO. Box 427, Barnstable, MA 02630 Ph: 508-375-6605 Page:. 1 of 1 1Y or nAky� CERTIFICATE OF ANALYSIS 'u Barnstable County Health Laboratory (M-MA009) Recipient: Sally Desmond Order No.: G18104698 Desmond Well Drilling Report Dated: 02/02/2018 P 0 Box 2783 Submitter: Well Driller Orleans, MA 02553 Description: 2 Day rush-RE Kit-315 Stoney Point Rd. r. . .... ---...._ __......_.__._.._..--- -_.._....----- - .._. ......................._-..........._...._....... --- . ---- - --- ---......... ......._ -- -------... .._.._................._.-._.._ ..........- - -- I!!Laboratory ID#: 18104698-01 Matrix: Water-Drinking Water f Sample#: Sampled: 02/01/2018 14:15 By: DWD I Collection Addr: 315 Stoney Point RD Cummaquid Received: 02/01/2018 15:07 By: PalmerP 'Sample Location: Turn Around: 48 Hr Rush Analyst: yn Method: EPA 524.2 Dilution: 1 Date Analyzed: 02/01/2018 @ 16:15 -- - ----- --- -- ._... ._......-.......------ -- - - ..._....._-- ---._--------------------- EPA 524.2- Vo/at'ile Organics by GC/MS Result MCL MQL Result MCL MDL r Parameter ug/L ug/L ug/L Parameter' ug/L ug/L ug/L Dichlorodifluoromethane ND 0.50 Chloroethane ND 0.50 Chloromethane ND 0.50 Chloroform 1.6 80 0.50 Vinyl chloride ND 2.0 0.50 cis-1,2-Dichloroethene ND 70 0.50 Bromomethane ND 0.50 cis-1,3-Dichloropropene ND 0.50 1,1,1,2-Tetrachloroethane ND 0.50 Olbromochloromethane ND 0.50 1,1,1-Trichl oroethane ND 200 0.50 Dlbromomethane ND 0.50 1,1,2,2-Tetrachloroethane ND 0,50 Ethylbenzene ND 700 0.50 1,1,2-Trichloroethane ND 5.0 0.50 Hexachlorobutadiene ND 0.50 1,1-Dichloroethane ND 0.50 Isopropylbenzene ND o.5o 1,1-Dichloroethene ND 7.0 0.50 Methylene chloride ND 5.0 0.50 1,1-Dichloropropene ND 0.50 Methyl-tert-butyl ether ND 0.50 1,2,3-Trichlorobenzene ND 0.50 Naphthalene ND 0.50 1,2,3-Trichloropropane ND 0.50 n-Butylbenzene ND 0.50 1,2,4-Trichlorobenzene ND 70 0.50 n-Propylbenzene ND 0.50 1,2,4-Trl methyl benzene ND 0.50 p-Isopropyltoluene ND 0,50 1,2-Dibromo-3-chloropropane ND 0.50 sec-Butylbenzene ND 0150 1,2-Dibromoethane(EDB) ND 0.50 Styrene ND 100 0.50 1,2-Dichlorobenzene ND 600 0.50 tent-Butyl benzene. ND 0.50 1,2-Dichloroethane ND 5.0 0.50 Tetrachloroethene ND 5.0 0,50 1,2-Dichloropropane ND 0.50 Toluene ND 1000 0.50 1,3,5-Trimethylbenzene ND 0.50 Total xylenes ND 10000 0.50 1,3-Dichlorobenzene ND 0.50 trans-1,2-Dichloroethene ND 100 0.50 1,3-Dichloropropahe ND 0.50 trans-1,3-Dichloropropene ND 0.50 1,4-Dichlorobenzene ND 5.0 0.50 Trichloroethene ND 5.0 0.50 2,2-Dichloropropane ND 0.50 Trichlorofluoromethane ND 0.50 2-Chiorotoluene ND 0.50 Compound %Recovered QC Limits(%) 4-Chiorotoluene ND 0.50 1,2-Dichlorobenzene-d4 106% 70 130 Benzene ND 5.0 0.50 p--Bromofluorobenzene 99% 70 130 Bromobenzene ND 0.50 -----.................------------...------�......._........_..--- ---------.._.._...........__ Bromochloromethane ND 0.50 Bromodichlorornethane ND 0.50 Bromoform ND 0.50 Carbon tetrachloride ND 5.0 0.50 Chlorobenzene ND 100 0.50 Attached please find the laboratory certified parameter list. Approved By• - - (Lab Director) ND = None Detected RL = Reporting Limit MCL= Maximum Contaminant Lev 3195 Main Street, PO, Box 427, Barnstable, MA 02630 Ph; 508-375-6605 Page 1 of 1 l r Massachusetts Department of Environmental Protection Bureau of Resource Protection Well Completion Reports. Well Driller Please specify work performed: Address at well location: [New Well V ---- Street Number: Street Name: 315 STONEY POINT RD Please specify well type: Building Lot#: Assessor's Map M Domestic 337 Assessor's Lot#: ZIP Code: Number Of Wells: 6 02637 City/rown: Well Location BARNSTABLE In public right-of-way: GPS r Yes f No North: West: 41.70821 70.27964 Subdivision/Property/Description: Mailing Address: click here if same as well location address Property Owner: Street Number: Street Name: GEORGE KITCHIN 36 BEAR SWAMP RD City/Town: State: Engineering Firm: ANDOVER CONNECTICUT ZIP Code: 06232 Board of health permit obtained: Of Yes r- Not Required Permit Number: Date Issued: W2018 003 01/24/2018 � Massachusetts Department of Environmental Protection ' Bureau of Resource Protection—Well Driller Program ' Well Completion Reports(General) Well Driller - General Well Form DRILLING METHOD Overburden Bedrock uger Choose Bedrock— WELL LOG OVERBURDEN LITHOLOGY From(ft) To(ft) Code Color Comment Drop in drill Extra fast or slow Loss or addition stem drill rate of fluid 10 Medium Sand �� Brown -r: SILTY SAND ES ( Fast r Slow ass ddition 10 20 Fine To Coarse S, Brown Fast �Slow =Lo.. Addton ) 1E 20 25 Medium Sand Brown f"Fast,-Slow YES NO Loss Addition WELL LOG BEDROCK LITHOLOGY Drop in Extra fast or Loss or Visible Rust Extra From(ft) To(ft) Code Comment addition of Large drill stem slow drill rate fluid Staining Chips P �� t J Choose Code r r Yes Yes - YES NO Fast Slow Loss Addition ADDITIONAL WELL INFORMATION Developed (�Yes f"No Disinfected f Yes Y'No Total Well Depth 25 Depth to Bedrock Surface Seal Type lNone racture Enhancement Yes fs No CASING r Is Casing above ground. From To Type Thickness Diameter Driveshoe 0 — 22 Polyvinyl Chloride Schedule 40 4 rl Yes SCREEN r No Screen From To Type Slot Size Diameter 22 25 Stainless Steel Well Point t 0.010 WATER-BEARING ZONES r DRY WELL From To Yield(gpm) 9.5 _ 25 12 PERMANENT PUMP(IF AVAILABLE) Pump Description Wire Constant Speed Horsepower Submersible f/ Pump Intake Depth(ft) 20 Nominal Pump Capacity(gpm) 10 Massachusetts Department of Environmental Protection Bureau of Resource Protection—Well Driller Progam ' <` Well Completion Reports(General) ANNULAR SEAL/FILTER PACK From To Material 1 Weight Material 2 Weight Water Batches Method Of (gal) (count) Placement Choose Material= Choose Material —Choose One— WELL TEST DATA ............ Time Pumped Pumping Level(ft Time To Recover Recovery(ft Date Method Yield(gpm) (HH:MM) BGS) (HH:MM) BGS) 2/1/201 B Constant Rate Pump 1.2� 1:30 12.5 0:01 9.5 WATER LEVEL Date Static Depth BGS(ft) Flowing Rate(gpm) Measured . 2/1/2018 9.5. 112 COMMENTS J 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. DESMOND — THOMAS E Monitoring[M] Supervising Driller III DrillerDESMOND III Registration# 764 Signature THOMAS,E DESMOND WELL Firm DRILLING INC. Rig Permit# 024 Date Job Complete 2/13/2018 NOTE:Well Completion Reports must be filed by the registered well driller within 30 days of well completion. t. No. � Fee BOARD OF HEALTH TOWN OF BARNSTABLE 01ppYicatiou _for Yell (Cou5tructiou permit Application is hereby made for a permit to Construct A, Alter( ), or Repair( an individual well at: Loc -Address I Assessors Map and Parcel C�c c�sL -, Pies c w r.r.a r�i�-. C'T 0(�Z32 Owner Address- ss Installer-Driller Address Type of Building Dwelling Other-Type of Building No. of Persons Type of Well 41 SCJN�,i O PSG Capacity ��}�(p1— Purpose of Well TCA_rjok�L_ Agreement: , The undersigned agrees to install the afore described 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 Certil a e of Compliance has been issued by the Board of Health. Signed At k IY e Date Q o Application Approved Bye Date Application Disapproved for the following reasons: Permit No. Issued Date -------------------------------------------------------------------------------------------------------- BOARD OF HEALTH TOWN OF BARNSTABLE (tertificate of (Compliance THIS IS TO CERTIFY,that the individual well Constructed 4 Altered( ), or Repaired( by IyiL Installer at '3 I S+e gy%" T-); + I�A C AAMINl 0.A ice.,CJ` has been installed in accordanci with the provisions of the Town of Barhstable 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 SATISFACTORILY. Date Inspector No. G' Fee - e BOARD OF HEALTH TOWN OF BARNSTABLE 01pprication ff or lVell Construction Permit Applications is hereby made for a permit /t'o Construct(✓), Alter( ), or Repair( an individual well at: 15 > t'Alno u �l1•, `^T �� yt bAwr.w.n_n�� Z�� (., Location-Address Assessors Map and Parcel 3c� R� G�C', .��k.AAo RIT �„�t�,.,�c- rTO 32 Owner d�—ess Installer-Driller T— ' Address Type of Building Dwelling Other-Type of Building No. of Persons Type of Well �}� SW9 0 e4c Capacity v Purpose of Well `c&jot,z_ Agreement: The undersigned agrees to install the afore described 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. Signed a A'. _ r �IIQ�IR � . Date Application Approved By Date Application Disapproved for the following reasons: w r "':9 •x r +., �; Date o Permit No. I Issued r 1 Date m—000ePoeseeemmemoo-evomveo_... — -----.._ae=.Qe BOARDOFHEALTH-------------------------------- EALTH..e -Q-sovemevoe— 4 ------- TOWN OF BARNSTABLE Certificate of Compliance THIS IS TO CERTIFY,that the individual well Constructed V), Altered( ), or Repaired( by Installer t at � �• prl;r�`�' K �4e�l� 1CA 0 a f1► has been installed in accordance with the provislons of the Town of Barn' stable 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 SATISFACTORILY. Date Inspector #621►T�..f iR 7f4ns..w.!�Jew+F�'Yae-sa�.r.a�T,ra�s+�.'l nv4y.IY.•.i e.+s�r.�wr+..r1�a.^w.+'fir �wsoos+.+�. :.�+.ur�.wcw+�.w�.er+:.�+.�i�:.. � �agik+_a.. r . BOARD OF HEALTH TOWN OF BARNSTABLE Yell Construction Permit o 0 0 17, No. w ( " Fee Permission is hereby granted to S A \ fl\ : 1\nn �1 /-- Installer to Construct('\A, Alter,(, ), or Repair( an individual well at: No. i Tcs,-1o�. '21:n�- 1 7 ,. .,a Ci LA i Street Was shown.on the application for a Well Construction Permit No. ;7a 6 a2 5 Dated Date t �� � �� Approved By /Iq V �j � / '00 .�. 337- 00( Commonwealth of Massachusetts L Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments - ,M 315 Stoney Point Road Property Address George and Coby Kitchin Owner Owner's Name 7:✓a information is required for every Ctquid Ma 02637 5/17/17 page. City/Town State Zip Code Date of Inspection ^ Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information S'/ Y filling out forms � / a 3a on the computer, use only the tab 1. Inspector: key to move your cursor-do not Michael DiBuono use the return Name of Inspector key. DiBuono Sewer and Drain r� Company Name 8 Johns path Company Address S Yarmouth MA 02664 Cityrrown State Zip Code 508-364-9587 S113522 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ 'Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approv' Authority 5/22/17 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts . - Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 315 Stoney Point Road Property Address George and Coby Kitchin Owner Owner's Name information is Cumma uid required for every q Ma 02637 5/17/17 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 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: System contains a block cesspool in front of three flo diffusers. The system is still functioning as designed. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): l5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal Systefn-Page 2 of 17 r I 1 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 315 Stoney Point Road Property Address George and Coby Kitchin Owner Owner's Name information is Cumma uid Ma 02637 5/17/17 required for every q 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 (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ :Y . ❑ N ❑,ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required-pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System wilUpass 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 El Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins 3113 ' °- Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts r W Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 315 Stoney Point Road Property Address George and Coby Kitchin Owner Owner's Name information is required for every Cummaquid Ma 02637 5/17/17 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: r 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 '/z day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4.of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 315 Stoney Point Road Property Address George and Coby Kitchin Owner Owner's Name information is Cumma uid Ma 02637 5/17/17 required for every G page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts r ' Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 315 Stoney Point Road Property Address George and Coby Kitchin Owner Owner's Name information is Cumma uid Ma 02637 5/17/17 required for every q 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? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ❑ ® Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3, Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 . Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 315 Stoney Point Road Property Address George and Coby Kitchin Owner Owner's Name information is Cumma uid Ma 02637 5/17/17 required for every q page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: Vacant Summer Res 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 197 Gpd 9 ( Y 9 (gPd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Date 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 Water meter readings, if available: t5ins•3/13 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments G1M , 315 Stoney Point Road Property Address George and Coby Kitchin Owner Owner's Name required for is every Cumma uld required for eve 4 Ma 02637 5/17/17 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: None provided Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ❑ Septic tank, distribution box, soil absorption system ® Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 315 Stoney Point Road Property Address George and Coby Kitchin Owner Owner's Name information is Cumma uid Ma 02637 5/17/17 required for every � page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1970 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1.5 feet Material of construction: ® cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Main line to cesspool appears to be newer Septic I pt c Tank(locate on site plan). 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 Dimensions: Sludge depth: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Offici al Inspection ection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 315 Stoney Point Road Property Address George and Coby Kitchin Owner Owner's Name information is required for every Cummaquid Ma 02637 5/17/17 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 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 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M a 315 Stoney Point Road Property Address George and Coby Kitchin Owner Owner's Name information is Cumma uid Ma 02637 5/17/17 required for every q page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 315 Stoney Point Road Property Address George and Coby Kitchin Owner Owner's Name information is Cumma uid required for every q Ma 02637 5/17/17 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert NA 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.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * 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: l5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 315 Stoney Point Road Property Address George and Coby Kitchin Owner Owner's Name { information is Cumma uid Ma 02637 5/17/17 required for every q page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type. ❑ leaching pits number: ® leaching chambers number: flo diffusers ❑ 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.): Soil around leach field is clean and dry 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 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts ; W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments �M 315 Stoney Point Road Property Address George and Coby Kitchin Owner Owner's Name isrequired for every Cumma uid Ma 02637 5/17/17 Cit /Town page. Y 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.): No ponding no break out 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 Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 315 Stoney Point Road Property Address George and Coby Kitchin Owner Owner's Name information is Cumma uid Ma 02637 5/17/17 required for every 4 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately - s t5ins 3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 315 Stoney Point Road Property Address George and Coby Kitchin Owner Owner's Name information is Cumma uid Ma 02637 5/17/17 required for every a page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 15+ ft 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: 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: Both usgs maps and clear site to water indicate water at or below 15' Before filing this Inspection Report, please see Report Completeness Checklist on next page. l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts W Title 5 Offici=al Inspection nForm a Subsurface SeWag6 Disposal System Form -Not for``Voluntary Assessments 315 Stoney.Point Road Property Address George and nd Cow Kitchin Owner Owner's Name information is Cumma uid: Ma 02637 5/17/17 required for every page. 0 City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately {X S Ce55 rdol V t5ins•3r13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments GSM 315 Stoney Point Road Property Address George and Coby Kitchin Owner Owner's Name information is Cumma uid Ma 02637 5/17/17 required for every 4 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ❑ Inspection Summary: A, B, C, D, or E checked ❑ Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ❑ System Information—Estimated depth to high groundwater ❑ Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 \ y •� Barnstable Harbor SM#4 \ d L ocus - S #N Post` n C � apt / S #3 \ \ APPROXIMATE WETLAND LOCA & STATE •\ EXISTING BOUNDARY C ° o COAST A BANK (TYP.) (OLD BOG) f qj / / /• t �,� O owe SALT MA SH �o ma co . c� j• ..�� S7 LOCUS MAP a So' e�F / COASTAL BARRIER \� I SCALE 1"=2000'f FAR RESOURCES E�� RPM \ ,-'' / SYSTEMS PRO�EC�N�w�s ASSESSORS MAP 337 PARCEL 6 LOCUS IS WITHIN FEMA FLOOD ZONE X / ♦ (AREA OF MINIMAL FLOOD HAZARD), ZONE AE (100 YEAR FLOOD HAZARD — EL. 12 1p ♦ AND EL. 13) AND ZONE VE (COASTAL BARRIER RESOURCES SYSTEM — EL. 15) AS I 14. 7 ^ f FFR ♦ I O SHOWN ON COMMUNITY PANEL #25001CO583J D / / ♦ � DATED 7/16/2014 a / PROPOSED WELL ZONING SUMMARY %• � � � `- � I \. ZONING DISTRICT: RF-1 RESIDENTIAL DISTRICT p ' / �-.�NDERGROUND MIN. LOT SIZE 43,560 S.F. FTR�OPANE TANK � � � MIN. LOT FRONTAGE 20' ^- .. MIN. LOT WIDTH 125' SM \ �EX�STjN` / MIN. FRONT SETBACK 30' \ APPROXIMATE \ EXISTING G i � MIN. SIDE SETBACK 15, p EXISTING DWELLING DECK / OR�VE AVED 0 MIN. REAR SETBACK 15' \ WELL T 0 MAX. BUILDING HEIGHT 30' \ �� ••\ / S R p EY poi 0 � \ 100—YEAR FLOOD © / AD /V), 4 \ HAZARD LINE (TYP.) OWNER OF RECORD \ GEORGE G. AND JACOBA C.B. KITCHIN, TRUSTEES \ o \• SHED '\ / KITCHIN REALTY TRUST S, •\ 36 BEAR SWAMP ROAD \ \ CP ` '•� f / ANDOVER, CONNECTICUT 06232 \ ''•\ i SHED REFERENCES DEED BOOK 18119 PAGE 10 \ PLAN BOOK 197 PAGE 77 NOTES ♦ h♦ _ __ \. \ \ ` •\ �- ---it_ ��''-�--_T_-_ •\, / 1. DATUM IS NAVD88 2. PROPERTY LINES ARE APPROXIMATE PER GIS. 3. THIS PLAN IS FOR PROPOSED WORK ONLY AND •'\ EXISTIN 16 ••\'' I NOTOTH TOPBE USE. FOR LOT LINE STAKING OR ANY OSE CESSPOOL ` VEXISTING LEACHING AREA I , 4. CONTRACTOR SHALL BE RESPONSIBLE FOR �•., CALLING DIGSAFE (1-888-344-7233) AND \ ♦ �5 ` I VERIFYING THE LOCATION OF ALL UNDERGROUND & APPROXIMATE --� '` I N OVERHEAD UTILITIES PRIOR TO COMMENCEMENT OF EDGE OF SALT ` WORK. MARSH THORENSEN, KRIS77NE SALT MARSH '2 1 PR0P0.e'Q>w* ED LL ••\ �� e'NITE PLAN` ` OF 315 STONEY POINT ROAD % CUMMAQUID MA PREPARED FOR .. _ GEORGE KITCHIN DATE: JANUARY 16, 2018 DATE: JANUARY 22, 2018 (WELL LOCATION) '••\ Scale: 1"= 20' ••� 0 10 20 30 40 50 FEET •` ��HOF dq �(NOFA4gysa Ss9cti aDANIEL cti� off 508-362-4541 DANIELA. ��� _ ��� fax 508-362-9880 �., O CiVIL OJAL..I downca e.com •�... ' " � A o � p �a No.. °J�'� P/ down nape engineefing, inc. SUR�� civil engineers land surveyors DATE DANIEL A. OJALA, P.E., P.L.S. 939 Main Street ( Rte 6A) YARMOUTHPORT MA 02675 DCE ## >8--00 >