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HomeMy Public PortalAboutBOH10.20.21packet�����uiuutirlllarrruru„r•/I i F_ W Ste: 0 _ ti fir//1//I/77j r �E0 0a Py°per Board of Health Penny Hole -man Annette GraczewsM Joe Ford Jeannie Kampas Kimberley Crocker Pearson Health Director Amy von Hone Assistant Health Director Sherrie McCullough Senior Department Assistant Tammi Mason Town of Brewster Board of Health 219$ Main St.,.Brewster, MA 02631 brhealth@brewster-ma.gov (508) 896,3701 BOARD OF HEALTH MEETING AGENDA 2198 Main Street October 20, 2021 at'7:00PM Pursuant to Chapter 20 of the Acts of 2021, this meeting will be conducted in person and v1 remote means, in accordance with applicable lave, This means that members of the public body may access this meeting in person, or via virtual means. in person attendance will be at the meeting lacation listed above, and it is possible that any or all members of the public body may attend remotely. No in-person attendance of members of the pub lickili be permitted, and public participation In any public hea ri ng co nd ucted during this meetingshaiI be by remote means only. Members of the public who whish to access the meeting may do so in the following manner: Phone: Call (301)715.8592 or (312)62E 6799. Webinar 10: 820 4394 4509 Passcode: 979174 To request to speak: Press *9 and wait to be recognized. Zoom Webinorr. httns://us02Web.zoom.us/i/920439445097nwd=MvtnM2kvUExKbU1R50hmM012b3dczzo9 Passcode: 979174 To request to speak: Tap Zoom "Raise Hand", then wait to be recog nlzed. When required by law or allowed by the Chair, persons wlshingto provide public comment or otherwise participate in the meeting, may do so by accessing the meeting remotely, as noted above. Additionally, the meeting will be broadcast live, In real time, via Live broadcast (Brewster GovemmentiV Channel 16), Livestream (livestream.hrewster-ma.gov) or Video recording (tv.brewster-ma.gov) 1. Call to Order 2. Chairman s announcements 3. Citizens forum 4. Maureen Steinmann -4 Daisy Lane : Leaching Facility Setback Regulation variance 5. Covid update 6. Flu Clinic update 7. Discussion to establish priority topics 8. Consent agenda: ■ 34 Winslow Landing Road -- Depth to cover variance ■ The Kitchen Cafe - Food -Service/ Catering permit 9. Liaison Reports 10. Matters not reasonably anticipated by the Chair 11. Next meeting: November 3, 2021 12. Informational items: a. Routine inspection for 39 McGuerty Road b: Routine inspection for 200 Brier Lane c. Maintenance Checklist for 200 Brier Lane d. Monthly report for King's Landing e. Field Inspection & Service Report for 5 Carsons Way f. Monthly report for Cape Cod Sea Camps g. Monthly report for Wingate 13. Adjournement Date Posted: Date Revised: Received by Town Clerk: 10/15/2021 s :max ,2 3"r•I U'i r ri r r llfiieserver161rdocuments$ItmasonlDesktoplAgenda tempIate. doex DigiSign Verified: DEF69A77-6CD4-44FE-8910-6E2C5F05E4E6 TowN of BREWS T L 90* -"s 2198 MAIN STREET It BIWSTLi, MA 42631 PHONE: (508) 896-370I ExT 1 1 FAx: (508) 896-4538 BRHEALTi O)BREWSTER-MA WWW.BREWSTER-MA.GOV ;.... orFtca or rf ry n FIs TH DEPARTMENT OCT )VIS Df=YART10E NT iH R6ceived.-j1q T Paid: n1►4 Application for Board of Health Variances Abutter Deadline; ❑Tn-House local Upgrade Approval [OPublic Hearing Date: October 8, 2029 SUBJECT PROPERTY ADDRESS: 4 Daisy Lane Brewster, MA 02631 Map: 56 Parcel: 82 - Book: Page: LC Certificate: LC Plan: Lot: Name of Applicant: Maureen Steinmann Mailing Address: '115-A Kristen Drive Ext., Chelmsford MA 01824 Telephone # 508-246-2083 Email: maureensteinmann@grnail.com Owner(s) of Record : Maureen Steinmann Mailing Address; Same Design Engineer/Sanitarian: Mailing Address: Telephone #: Email address: FirmXompany Name: Signature: A0)lVAV96AaM Applicant or Engineer New Construction ❑ Voluntary Upgrade © Add itlon/Alteration ❑ Failed system ❑Real Estate Transfer P Design flow of existing system: Design flow of proposed system: Total sewage flow of site: Conservation Commission approval required: yes ❑ no ❑ Order of Conditions/Det. Of Applicability attached ❑ Reason For failure: Total lot size (so: Date of ConCom hearing: List of all Variances from States and Local codes add sheets if needed TITLE 5 Sec. #: Description of Variance(s) Brewster Reg. #: Description of Variance(s) #99 Request to leave SAS 220+1- from Schoolhouse Pond Approved by: Date: Health Department N:I1iealthM0H regs\tnHouse Septic Local Upgrade Approval 2019Wadaneoapplicatinn FINAL NONFILLABLE FORM 12,18.19,doox Vk IE We /0 �!i 0 19. A Town of Brewster 2198 MAW STREET BREWSTER, MASSACHUSETTS 02631-1898 PHONE: 508.896.3701 EXT. 1120 FAX: 508.896.4538 brhealth@brewster-ma.gov WWW.BREWSTER-MA.GOV AGENDA ACTION ITEM FORM BOH Variance Agenda Item 0 In -House Local Upgrade Approval El Other: 0 Board of Health Meeting Date: October 20, 2021 Project Location: 4 Daisy Lane Map & Parcel: 56/82 Owner's Name & Address: Maureen Steinmann I I 5-A Kristen Drive Extension Chelmsford, MA 0 1824 Applicant: same as above Date Requested: October 8, 2021 Title 5 Variance Request: Board of Health Variance Request: Other: Health Department Amy L. von Hone, R,S., C,H.0, Director Sherrie McCullough, R.S. Assistant Director Tammi Mason Senior Department Assistant Yes[] NoEl YesM NoE)300'Pond Setback Yes EJ No 0 1. Outside Zone 11 and Town Water 2. In ESA — existing dwelling and septic system within 227' +/- of Schoolhouse Pond (218'+/ - of wetland edge) 3. Real Estate Transfer' Inspection July 29, 2021 for Property Sale 4. Real Estate Transfer Inspection August 25, 2017 for Property Sale — Passed report without 300' setback variance request Health Director's Comments and Recommendations: I . The property consists of an existing 3 bedroom dwelling with a 2000 Title 5 septic system consisting of a 1500 gal septic tank, 1000 gal pump chamber, distribution box, and a leach facility consisting of 4 — 500 gal precast chambers with 2' stone approved for a 4 bedroom dwelling per office records. The property borders the southeasterly side of Schoolhouse Pond. The existing leach facility is approximately 227" from the closest edge of the pond, 218"+/- from the closest edge of wetland, and approximately 9' +/- above the edge of the pond elevation per N:�HealftBOH Meeting Notes\BOH Hearing Notes\4 Daisy Ln M56P82 Agenda.Variance Action Item Form 10,20,202 Ldoex the July 29, 2021 Title 5 Inspection Report. The leach facility is not showing signs of hydraulic failure (0" ponding in a 24" deep chamber system). 2. Per the Water Table Map of Brewster and Harwich, groundwater is flowing northwesterly towards the pond. Based on the location of the leach facility, the leach facility is located upgradient of Schoolhouse Pond. 3. Map References: - Cape Cod Water Resources Classification Map 1, 6/18/2010 (Map referenced in approved BOH Regulation Regarding Variance Requests for On -Site Sewage Disposal System Applications): lot and septic system are located within the Freshwater Recharge Area. - Septic System Buffers and Groundwater Flow Directions near Brewster's Ponds, 1/26/2016 (Map referenced in Draft BOH Regulation of Sewage Disposal Systems to Protect Surface Waters and Pond Water Quality, 2016): the lot and septic system are located within proposed septic system setback delineated boundary. Draft regulation not currently approved by BOH. Septic system pre-existed draft regulation and map. - Water -Table Map of Brewster and Harwich, 1987 (Map referenced in approved BOH Regulation Regarding Variance Requests for On -Site Sewage Disposal System Applications): septic system located upgradient of southeasterly end of pond. 4. Title 5: no variances requested — pre-existing conditions Town of Brewster: a. SAS 227'+1- to Pond edge, 73' variance request per Leach Facility Set Back Regulation (5) 5. Approval with the following reasons: a. Septic system has a passed Title 5 Inspection Report dated 07/29/2021 and indicates the system is properly functioning. b. The leach facility is greater than the minimum 5' separation above the pond elevation/groundwater required under Title 5 regulations. Per file records, the leach facility is approximately 9' above groundwater/pond elevation. c. The existing leach facility is a 1995 Title 5 Code system that is located parallel to the pond edge and is a pump system providing equal distribution of the sewage over the entire leach facility. The orientation and the distribution method are providing some mitigation of phosphorus and nitrogen compared to a gravity fed system. NAHea1th\RO14 Meeting NoteslBOH Hearing Natesl4 Daisy Ln M56P82 Agenda- Variance Action Item Form 10.20.2021. do ox Cod dilater Resources Classification Map I Regional Policy Pian (Effective JanuaYy 16 Amended -- Effective Judy 3, 2009 Amended -- Effective June 18, 2o1n Primary Resource Areas: F— Wellhead Protection Areas Identified Wellhead Protection Areas: (Zcnes of Ccxnrf9Won). Department of Environmental Protection and EOEA MassGIS 2010, Cape Cad Commission Water Resources Staff, and various private consu Public Supply Wells A Public Water Supply Well Small Vclume Wells, NonTrairsient 07 mall Vclurne Wells, Transient d Proposed FuNic Water Supply Well a Surface Water Supply Locations of pubic community surface and groundwater supply sources public nor -community supply sources. Department of Environmental Prc and EOEA MassGIS 201D, and Cape Cod Commisshn Water Resources S Potential Water Supply Areas ?y , Potergia€ Public Water Suppry Tracts. From the "Priority Land Acquisition Assessment Project" (PLAAP), June 1999, updated 2008, Lower Cape data from the Lower Cape Water Quality Task Force, 2001, i. lYeshwater Recharge Areas ENS• g Freshwater Recharge Arra: Areas shown are those identified To DATE h (see reports 2034-5414 and 2004-5181), the Massachusetts Estuanes Pr 3 ; the Cape Cod Commission Water Resources Staff, 2008. `+ Water Duality Impaired Areas Developed Areas Development such as me-dTim and high density residential, multi family: unsewared residential lots less than 20,003 square feet, commercial and inlustrial areas determined from digital parcel and assessors' data and h [ landuse: 1999. Created by UMass-Amherst Resource Mapping Prcjxt in with the ECI A MassGIS project and the Cape Cod Commission. Potential Plumes fi am Waste Sites N^ - Potential Plumes from Waste Site Areas: Created from private consultiu the Air Force Center for Engineering and the Enviro mert and the Cape Commission Water Resources Staff, - hl Waste Site Areas Areas that Imiude landfills, septage, and wastewater treatment grant dls determined from digital parcel aril as'eors' data and digital MacConne 1999. Created by the LIMass-Amherst Resource Mapping Noject in cooperation with the EDEA Ma5sMS project aril the Cape Cod Comrrd Water Quality Improvement Areas: Water CtuaYty Impaired Areas that are located In Primary Resource Area: Thts Map was poduoed by the Cape Cod Ceinmiss;m's Geographic Information Slstem Deparhnsnt for the Regional Pdlq Plan update, efke We]amFay 16, 2DO5, 00 any ammdmarrts rated beW: Data amendments ei4erWe juty 3, :5W radudxV DEP ?me Its, DEP P+.hllc Suppy Weks, and the Cape Cod O]mrww1m PUMP. Data amwdmer>!s effective June 16, 2016 Wading Welhead Protection Areas and DEP Public SWply WeAs. The Cape CGd Commnim u a dFeisim of Banutable County. Corrections a2 iWwm at the Cape Cod Lbmmssion once or contact gis@�capemdrenrnission.org. M trap is ilRtstralive and all deplctad baundxies are appvmdmate. It is ntended for ptamYg purpms cciYj -- not slW spalric parposas. CAFE COD C01MiMISSION . . :sem; Regional Policy Pian (Effective JanuaYy 16 Amended -- Effective Judy 3, 2009 Amended -- Effective June 18, 2o1n Primary Resource Areas: F— Wellhead Protection Areas Identified Wellhead Protection Areas: (Zcnes of Ccxnrf9Won). Department of Environmental Protection and EOEA MassGIS 2010, Cape Cad Commission Water Resources Staff, and various private consu Public Supply Wells A Public Water Supply Well Small Vclume Wells, NonTrairsient 07 mall Vclurne Wells, Transient d Proposed FuNic Water Supply Well a Surface Water Supply Locations of pubic community surface and groundwater supply sources public nor -community supply sources. Department of Environmental Prc and EOEA MassGIS 201D, and Cape Cod Commisshn Water Resources S Potential Water Supply Areas ?y , Potergia€ Public Water Suppry Tracts. From the "Priority Land Acquisition Assessment Project" (PLAAP), June 1999, updated 2008, Lower Cape data from the Lower Cape Water Quality Task Force, 2001, i. lYeshwater Recharge Areas ENS• g Freshwater Recharge Arra: Areas shown are those identified To DATE h (see reports 2034-5414 and 2004-5181), the Massachusetts Estuanes Pr 3 ; the Cape Cod Commission Water Resources Staff, 2008. `+ Water Duality Impaired Areas Developed Areas Development such as me-dTim and high density residential, multi family: unsewared residential lots less than 20,003 square feet, commercial and inlustrial areas determined from digital parcel and assessors' data and h [ landuse: 1999. Created by UMass-Amherst Resource Mapping Prcjxt in with the ECI A MassGIS project and the Cape Cod Commission. Potential Plumes fi am Waste Sites N^ - Potential Plumes from Waste Site Areas: Created from private consultiu the Air Force Center for Engineering and the Enviro mert and the Cape Commission Water Resources Staff, - hl Waste Site Areas Areas that Imiude landfills, septage, and wastewater treatment grant dls determined from digital parcel aril as'eors' data and digital MacConne 1999. Created by the LIMass-Amherst Resource Mapping Noject in cooperation with the EDEA Ma5sMS project aril the Cape Cod Comrrd Water Quality Improvement Areas: Water CtuaYty Impaired Areas that are located In Primary Resource Area: Thts Map was poduoed by the Cape Cod Ceinmiss;m's Geographic Information Slstem Deparhnsnt for the Regional Pdlq Plan update, efke We]amFay 16, 2DO5, 00 any ammdmarrts rated beW: Data amendments ei4erWe juty 3, :5W radudxV DEP ?me Its, DEP P+.hllc Suppy Weks, and the Cape Cod O]mrww1m PUMP. Data amwdmer>!s effective June 16, 2016 Wading Welhead Protection Areas and DEP Public SWply WeAs. The Cape CGd Commnim u a dFeisim of Banutable County. Corrections a2 iWwm at the Cape Cod Lbmmssion once or contact gis@�capemdrenrnission.org. M trap is ilRtstralive and all deplctad baundxies are appvmdmate. It is ntended for ptamYg purpms cciYj -- not slW spalric parposas. CAFE COD C01MiMISSION Z11,1e A�o 1,092- z No. �' Dats ..:L ... E��I�IE� BREWSTER, MASSACHUSETTS New Installation U BOARD OF HEALTH Repair JUN 12 2000 $215.00 Application for Disposal Works ConstruC4RN& BOARD Application is hereby made for a Permit to construct W or Repair ( ) an individual �adwb66u System at: .'�. LIAlAy. Lfw� .. ................... 1!?n� . 4j .. f��. 6'9 ....................... I aeaeian-Addrda ' Lot 1,1A,. AliP i Loi No. pAb, °� - �f HAY .. ................... lel. � +.t► ►�vR .A ..,. hlr r x+�nr.,.rAC, zooc�3 er . . ................. .....................Add .................... . T[IS[ Ci 'Add[tl1' Type of Building Size Lot jNW50.Q } .. Sq.feet ` �; Expansion Attic ( ) Garbage Grinder (-*) Dwelling --No. of Bedrooms ...... � ... r' �,. Other—Type of Building ................... No. of persons , ..................Showers( ) —Cafeteria( ) Otherfixtures............................................................... .... ... Design Flow . ... ,? ..... ....gallons per person per day. Total daily flow.. `/ 0., ........... ...gallons. Septic Tank—Liquid capacity .15PO .... gallons Length . ... Width .45 Diameter ...Depth Disposal Trench—No. ..... f...... Width .. JZ : .. .Total Length ...YT. '. . . Total leaching area ..8l :'Q..... sq.ft. Seepage Pit No... .. . Diameter ........... Depth below inlet ........... Total leaching area ........... sq. ft. Distribution box ()() Dosing tank (X) Other ...................... . ... . . ................................. . Percolation Test Results Performed by .p Qsji-W&-Y)V►` M. eldre,4hee. Date .... rlr 14.xN ........... .. . th to Test Pit No. 2 ... .... minutes per ch Depth of Test Pit . J.Y.. I. ;' ... Depth to ground inchround water .. tq W 4"z.... . Descripion of Soil .. Sp+t-tom.. �..�P:�?�f . �4� .............. ,........................................................ ............ . Nature of Repairs or Alterations -Answer when applicable . 7C.x►s�t��P, ..ra . .:Fi�ioYA.................... . NUTS: This application must be accomopanied by a plan showing the following: property lines, location of buildings, location of proposed sewage system, any existing sewage system, well or water line, water supplies on adjacent lots, loca- tion of driveway and or parking area, location of any adjacent bogs, marshes, wetlands, ponds, streams, beaches or drains, and expansion area. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the pro- visions of Title 5 of the State E ' Code—The undersigned further agrees not to place the system in operation un- til a Certificate of Complian has b is ed b th oard of Health. Signed. ...... .. .... ... . . ..... . Application Approved By. �V-1 r; .......... G �: C�� 1.. ... Application Disapproved/Restrictions ..........................97 . ....................... ................................................. I....................... ........... LUW.......... — ------ BREW5TER, MASSACHUSETTS Fee.—.._._..M�.—+. BOARD OF HEALTH Disposal Works Construction Permit �E � :'k Permission is hereby granted ...1. ' �-' . 4 ... ......... ..................................... . to Construct (�Jj or Repair{ !) an Individual Sewage Disposal System at Lot. r7 . [ ...... Map. .�i........... q. .. -.`:: Il . [l as shown on the application for Disposal Works Construction Permit No ..... Dated ................. DATE ...:.:'� 741--. .... , ...................... C; ' ■p:i di�Ii�:tut 0 010* %0 11. V T� 0 �EE Town of Brewster Health Department 2195 Main Street Brewster, Massachusetts 02631-1898 (508) 896-3701 Ext. 120 FAX (508) 896-4538 R EC E IV ED EF C EV EF D AUG 0 6 292, K 13REWS-raR -1E DE D �P4 -rij _%4 1, A T RTME E L NT FEE:t SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPEt'TION FORM APPENDIX BREWSTER REGULATION Map, 5 6 11—D 8 2 Property Address:_ alsy ane Owner Address: Maureen Sf . n, 115-A Kristin D �ive Ext.� Chelmsford, MA 01824 NameofInspector Forrester L. Quinn ColnPany Name, Address &Phone Number _T_-L_-__QuTnn -59T--Z53-- Zi: �=T.__0_r_.Fe_a _ns 2 6 5 3 Dale ofinspectian:_ 7/29/2021 Th is 1, '-spection represents (check one) K) Real Estate Transfer () Addition/alteration k�AA) System Passes -.---B) System Conditionally Passes --.Septic tankcovers are inore than 12 inches below the finished gntdc. IiV-712_1 Altal�j( -3 Q Further evaluati on is required by the Board of Health �_6v *Aek 104�7 .—Records show excessive Pumping three or more times within any eighteen (13) rnPh r5iod(foAr=4Vjd/enfial r e4�1, Commercial propeny; except for required grease trap maintenance for commercial property. __�L'rhc ;each I ng faci I ity or faci lilies are located within 300 feet of a pond or lake D) Systern Fails (Brewster Real Fstate Transfer requirements) ___7_ The system i s in a state of disrepair such that it cannot function as j t was original Jy I ntendcd; ----The lack of a 4 foot protective zone between the bottorn of thesystem and the groundwater; Any other problem as defined by the Board of Health or its Director; _—The sewage disposal system consists of a single cesspool, ol. cesspaois. The Brewster Heafth DePariment has rcvieiycd and accepted this report based on the information contained thercin. 'I'his inspection reflects the present condition ofthe Sanitary System and is not any guarantce as lo the life or futurc condition of said system. h11 Ap prov I ng A uth o r i ty Date PI case he advi �,-d of ADj)j,rjONAL 130ARD 0F_lj1l­-.AlTl` I R�('Ju LATIONS: I Al I private wel Is are requ ired to be analyzed prior to approval of the Subsu rface Sewage Di sposal System Inspection form, and sixty (60) days prior to transfer of property, Commonwealth of Massachusetts S.~{P Title 5 Official Inspection Farm Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 4 Daisy Lane — Parcel ID: 56-82 Property Address Maureen_ Steinmann 1155A Kristin Drive Ext., Chelmsford, MA 0'1824 Owner rdame information is required for every Brewster_ _ _ MA _ 02631 _ _ 7/291202'1 page. City/Town _v State zip Code Date of Inspection Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. rah 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. A. Inspector Information Forrester L. Quinn Name of Inspector F.L. Quinn Company Name P.O. Box 514 Company Address Orleans CltyrTown 508-255-4544 _ Telephone Number B. Certification _ MA State -- – _-- SI596__ License Number 02653 Zip Code I certify that: I am a DEP appror►ed system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my Inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined tht the system: Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails ISignature — — — pa 1 V 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 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 form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: 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. 15insp. doc • rev- 7!2612018 Tine 5 0ffoW 1^ispection Form: Sub surrace Sewaga Disposa! System - Page 7 of 18 Commonwealth of Massachusetts �. Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 4 Dais Lane Parcel ID: 56-82 Property Address Maureen Steinmann (115-A Kristin Drive Ext. Chelmsford, MA 0182_ Owner Owner's Name information is Brewster required for every MA 02631 7/2912021 page. CitylTown State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 11) System Passes: Ll l 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: 2) 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 determinedW (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): 152ksp.ft, • rev. 7126MI B Title 5 Widal InspeoMon Form' SLOSWace Sewage Disposal System • Pag® 2 of 1 B (1011, Commonwealth of Massachusetts ��- Title a official Inspection Form Subsurface Sewage Disposal system Form - Not for Voluntary Assessments 4 [3_ airy Lane _ -Parcel ID: 56-82 Property Address T -- -� - - - — Maureen Steinmann (1 15-A Kristin Drive Ext., Chelmsford, MA 61824 Owner owner's Name — - — — informato-on is Brewster required for every _ _ _ _ _ _ MA 02631 7/29/2021 page. Cityl7own State Zip Code Date of Inspection C. inspection Summary (cont.) 2) System conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipes) 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): 3) 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. a_ system will pass unless Board of Health determines in accordance with 310 CMR 95.303(1)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp. doc • rev. 712 612 01 6 Titla 5 official Wr pec lion Form: Seibsurfa::a Sewage Disposal Sysdem • Page 3 of 18 Commonwealth of Massachusetts �9 Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form - Not for Voluntary Assessments r 4 Daisy Lane Property Address — — `-- `—^— —— Maureen Steinmann 115-A Kristin Drive Ext., Chelmsford, MA 01824 Owner Owner's Name information is required for every Brewster Y�v _ MA 02631_ page, CitylTown State Zip Code C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water Parcel ID: 56-82 7/29/2021 ❑ate of Inspection ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. 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 fess 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. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or "No" to each of the following for all inspections: Yes No ❑ d 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 t5insp. doC • rev. 7/2612016 TA 9 5 OfticlaI 4ispect[on Frxm: Subsurface Sewage UspoW System - Page 4 of ]B Owner inforrnation is required for every page. Commonwealth of Massachusetts Title a Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 4 Daisy Lane _ Parcel ID: 56-82 Property Address -- Maureen Steinmann 115-A Kristin Drive Ext., Chelmsford, MA 01824) Owner's Nan a Brewster _ MA CitylTown State C. Inspection Summary (Cont.) 02631 7/29/2021 Zip Code Date of Inspection 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ d Liquid depth in cesspool is less than 6" below invert or available volume is less than % day flow ❑ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipes), 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 water supply well. ❑ E Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ El/ 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 2000 gpd- 10,000 gpd. ❑ 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. 5) 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 C,4, 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 t5mspAoo - rev. 7126/2010 Ti11a 5 nffiOW Inmpectorl Farm; Subsurface 9ewage Disposal Sgstsrn • Page 5 of 18 Commonwealth of Massachusetts - (p, Title 5 official inspection Form e Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �"'�r 4 ❑ai5 Lane �� -- - -- — --- - --- - - Parcei ID: 56-82 Property Address -� ---- -- -- -- Maureen Steinmann 115-A Kristin. Drive Ext., Chelmsford, MA 61824 Owner Owner's Name �--� --- information is '4 required for every Brewster y ___ _MA 62631 7/29/2621 _ page. Cityffown V� State Zip Code date of Inspection C. Inspection Summary (cont.) If you have answered "yes" to any question in Section C.5 the system is considered a significant threat, or answered "yes" to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. 'You must indicate "yes" or "no" for each of the following for all inspections: 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? ❑ [0� 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 examiner!? (If they were not available note as NIA) d❑ Was the facility or dwelling inspected for signs of sewage back up? d ❑ 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? ❑ d 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: L J ❑ Existing information. For example, a plan at the Board of Health. ❑ Determined in the field (if any of the failure criteria related to Pan: C is at Issue approximation of distance is unacceptable) [316 CMR 15.362(5)] t&Lksp-duc • rev. 712612018 Titfe 5 Official Inspection Form: Subsurface Sewage Disposal System • page 6 or 1a Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments r 4 Dais Parcel 1D: 56-82 Property Address Maureen Steinmann(115-A Kristin Drive Ext., Chelmsford, MA 01824 owner's—Name Owner— -- --- -- information is Brewster required for every _ MA 02631 7/29/2021 page. Cityfrown T ~ State Zip C _ ode Date of Inspection D. System information 1. Residential Flow Conditions: I 1 Number of bedrooms (design): --J�--- Number of bedrooms [actual]: DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): -44b Description: W? VU -40K aox Kai Number of current residents: Does residence have a garbage grinder? Does residence have a water treatment unit? If yes, discharges to: Is laundry on a separate sewage system? {Include laundry system inspection information in this report,} Laundry system inspected? Seasonaluse? Water meter readings, if available (last 2 years usage (gpd)}: a01 Detail: ❑ Yes EB(Ao ❑ Yes Ef No ❑ Yes a No ❑ Yes [r` No ❑ Yes [�'I No Sump pump? Y~ � T ❑yes eNo Last date of occupancy: _ eat 1 Date Mgsp.doo • rev. 71261ZO10 Title 5 OiroaeC Inspection Form: Subsurface sewage Disposal System • Page 7 918 3- Pumping Records: Source of information: Was system pumped as part of the inspection . If yes, volume pumped: Mow was quantity pumped determined? Reason for pumping: ��4_a4lj_ _40. 7 ❑ Yes 0 No gallons t�insp. doc • rev. 7126!2016 Tidos 5 Official lnspecli= Form: Subsurface Sewage (Asp DSaI System • Aaga 8 of 1B Commonwealth of Massachusetts _ - - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �5 i 4 Daisy Lane Y Property—Address Parcel ID: 56-82 – Owner Maureen Steinmann 115-A Kristin Drive Ext., Chelmsford, —��- .— -- MA 01824 ��— information is Owner's Name re q u ire d for every page. BrewsteryTy - y--y--TM-- MA _ Cityrrown 02£31 7/29/2021 State Zip Code Date of Inspection D. System Information (cont.) 2. Commercialllndustrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15,203);_ -- Gallons per day (gpol) Basis of design flow (seatslpersonslsq.ft,, etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: -- - - -- - - -- -- - __- _-� —_- �- - Industrial waste holding tank present? ❑ Yes ❑ No Non -sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: --- -- -----� `- __- Last date of occupancy/use: pate Other (describe below): 3- Pumping Records: Source of information: Was system pumped as part of the inspection . If yes, volume pumped: Mow was quantity pumped determined? Reason for pumping: ��4_a4lj_ _40. 7 ❑ Yes 0 No gallons t�insp. doc • rev. 7126!2016 Tidos 5 Official lnspecli= Form: Subsurface Sewage (Asp DSaI System • Aaga 8 of 1B Commonwealth of Massachusetts Title 5 Official inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments J 4 Daisy_ Parcel ID: 5E-82 Property Address -- Maureen Steinmann 015-A Kristin Drive Ext., Chelmsford, MA 01824)— Owner ❑wvner Name — — --- information is required for every Brewster_� _y _ MA _ 020_31 7/29/2021 page. Mt -y Town �~ State Zip Code Date of Inspection D. System Information (cont.) 4. 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) ❑ Inncvative/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 IIA system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. Other (describe): --- --Pqo*— ---- - - - -- Approximate age of all components, date installed (if known) and source of i7- Were ation: -- -- van -A lrVS7?�►dC� �a _ -- -. -- DG ` L ) sewage odors detected when arriving at the site? ❑ Yes ETO'No 5. Building Sewer (locate on site plan) 4.w Depth below grade: ---- feet Material of construction: ❑ cast iron g40 PVC ❑ other (explain): — - Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): [5105p.doc • rsv- 7/2612018 Title 5 dffcl®1 Inspectlon Form: 8uhsudece Sewage DISgiosill Syslem • Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form kqt��j Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 4 Daisy Lane Parcel ID: 56-82 Property Address "`T W _Maureen Steinmann (715-A Kristin Drive Ext., Chelmsford, MA 01824 Owner owner's Dame information is required for every Brewster_ MA 02631 7/29/2021 page. City/Town State Zip Code Date of Inspection D. System Information {cont.} 6. Septic Tank (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal El 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: 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.): -29 vk- rr� ��' /fJ ��c71 ___v `r _ ■,Glc !�•r�L 1°t•�" �7����. /1/!/C rZ. — � ICT' WKSP.&C • M, 712W2018 Title 5 OfWal Inapection Form: Subsurface Sewage 01spossl System • pegs 10 d 18 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 4 Daisy Lane — Parcel ID: 58-82 Property Address — Maureen Steinmann 115-A Kristin Drive Ext., Chelmsford, MA 01824) Owner owner's Name— nformation is Brewster required for every MA 02831 7128!2021 page. CItyl7own State Zip Code Date of Inspection D. System Information {cont.} 7. Grease Trap (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal Dimensions. Scum thickness feet ❑ fiberglass ❑ polyethylene ❑ other (explain): 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.): 8. 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: — galbns Design Flow: galbons per day t5irisvdac • rev. 7/2612018 TRIe 5 Offidal Inspection Farm: Subsurrace Sewage Olsposal System • Pago 11 of 1 B Commonwealth of Massachusetts Title 5 Official inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 4 Dais Lane Parcel ID: 56-82 Property Address Maureen Steinmann 915-A Kristin Drive Ext., Chelmsford, MA 01824) Owner owner's Name information is Brewster required for every MA 82631 7/29/2021 page. cityrrown State Zip Code Date of inspection D. System Information (cont.) 8. Tight or Holding Tank [cont.} Alarm present: Alarm level: Date of last pumping: 'es ❑ No Alarm in working order: ❑ Yes ❑ No Date w Comments (condition of alarm and float switches, etc.): * Attach copy of current pumping contract (required), Is copy attached? 9. Distribution Box (if present must be opened) (locate on site plan): ❑ Yes ❑ No 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.): Lout, OU 1 %7- Arse j vJ ► 'if% / �locU C../3 [ 15insp.doc • rev. 71261201 0 Title 5 pKGal lnspeu6m Farm: Subsur[aoe Sewage Disposal System • Page 12 at 18 Commonwealth of Massachusetts Title 5 Official Inspection Form } Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 4 Daisy Lane Property Address _Maureen S_teinm_ann (115-A Kristin Drive Ext., Chelmsford, MA 01824 Information is o Owner Maureen Name rn required for every Brewster MA 02631 page. Cityrrown State Zip Code D. System Information {cont.} 10. Pump Chamber (locate on site plan): Parcel 1D: 56-82 7/29/2021 Date of Inspection Pumps in working order: Yes [] No* Alarms in working order: Z 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. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits [� leaching chambers RW -1(S ❑ leaching galleries ❑ leaching trenches ❑ leaching fields ❑ overflow cesspool ❑ inn ovativelalternative system Type/name of technology: number. number- t��iON� number: number, length: number, dimensions: number: t5lnsp.d= - rev, 712GIro18 Title 5 offaaia! Inspection Farm: Subswrace Sewage Dlaposal System • Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form A Subsurface Sewage Disposal System Form » Not for Voluntary Assessments 4 Daisy Lane Property Address Parcel ID; 56-$2 —~ �� Owner Maureen Steinmann (115-A Kristin Drive Ext., Chelmsford, MA 01824 information dwnees Name is required for every Brewster _ MA 02631 7/29/2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): 0 �r Ti4 12. 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, etc. ): t6Mp.63c • rev. 712SM16 Title 5 Offdad Inapechm Form: Subsurface Sewage Disposer Systaan • pa 14 of 18 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System P y Form Not for Voluntary Assessments 4 Dais Lane --- - --- ID: 56-82 Property Address � - - - �- - - - - -------___Parcel _ Maureen Steinmann [115-A Kristin Drive Ext, Ch -elmsford, MA 01824` Owner Owner's Name �- —T-- - informat6on is required far every Brewster_ — _ __ MA_ 026317/29/2021 page. Qt—Y/Tmvn State ZIp Code Date of Inspection_ D. System Information (cant.) 13. 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.): l5inep-don • rev. 712812018 Tille 5 Off cfal InspeNncn Form: Subsurfsca Sewage ousposal Syslem • page 15 of I E= - Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 4 Daisy Lane Property Address Parcel I D: 56-82 Maureen Steinmann (115-A_Kristin. Drive Ext., Chelmsford, MA 01824) Owner Owner's Name information is required for every Brewster MA 02631 7/29/2021 page. cityrrown state Zip Code date of Inspection D. System Information {cont.} 14. 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 tt'insp.doc • rev. 712 6126 1 8 a Ft7 2 15' S` A 3 24' g►5,. 4 r 51' A4' c��eJ CY,Le&&+r A s c o J 1 9' 11,5 D tt'insp.doc • rev. 712 6126 1 8 Title 5 Officio Inspection Farm SubsWace Sewage Disposal System • Page 16 ar IS „ 2 15' S` 3 24' g►5,. 4 51' A4' Title 5 Officio Inspection Farm SubsWace Sewage Disposal System • Page 16 ar IS Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 4 Daisy Lane ` �^ y` Parcel ID: 55-82 Property Address Maureen Steinmann 115-A Kristin ❑rive Ext., Chelmsford, idlA 171824) Owner owner's Name information atifo a rY Brewster _ _ _ required for eve PIlIA 02631 7/29/2021 page. Cityrrown state Zip Code hate of Inspection D. System information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 9 Uo ` e077z"4 C'1. 00C .SRO feet ^00 W 641'ErJL f 60W-0 Please indicate ail 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: 04Al t97-6� `o���' � _. �,.��r 51 Ft o T"f 1. coo Before filing this Inspection Report, please see Report Completeness Checklist on next page. Onsp.doc • rev. 7/2612618 T& 5 Official lnspecloan Fcrm: Subvirface Sewage LNsposel Syclem • Page 17 of 16 Commonwealth of Massachusetts Title a official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 4 Daisy bane Property Address -- - -- — -- --- __-- Parcel I D: 56-82` Maureen Steinmann 115-A Kristin Drive Ext, Chelmsford, MA 01824 Owner 6-Wner's Name —� ----- information -- es required foreve ry Brewster__ _MA 026_31 7/29/2021 page. CitylTown State Zip Code Date of Inspection TM E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: A. inspector Information: Complete all fields in this section, B. Certification: Signed & Dated and 1, 2, 3, or 4 checked C. Inspection Summary: 1, 21 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist) completed D. System Inforrnation; For 8: Tight/Holding Tank — Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg, 16 or attached For 15: Explanation of estimated depth to high groundwater included t5hsp.doc • rev. VM2018 Tilde 5 ❑FfCIaI inspection Firm: Subsurfaca Sewage Dispose! System • page 18 of I t °newar� � �, TOWN (]F)RPX VSTER •� s9> OFFIC&OF 2198 IY;C&IN STREET 'HEALTH r]EaARnj4-M R BREWSTGR, MA 0263I ��Yy; PtOrre: (508) 896-3701,EXT 1320 `tltir FAX: (548)89&,4538 8R3i.ALTMRORMYSTER-1f A,GOV ADDENDUM TQ SEPTIC INSPECTION REPORT inspection Location: 4 Daisy Lane Maty &Parcel: s 6 r $ 2 1. ]%aside i € Pro e # of rooms Bedrooms Family Rooms Living Roorns Bathrooms Dining Rooms Kitchens other; Total: 2. Flonr Plan: Sljow a€I floors includin basement: Commercial Fro a Employees Toilets Rooms with bath Square Feet 3, 4 Is the septic system, as inspected, in full compliance with s If riot, list deficiencies; itltar the 197g( ) ar 1995 (O/Title 5 Coda? Yes �Nv Is the systern in the Zone lI (Wel 11)cad Proteotion Area) ares 'Np Lot size:.k S 6O ilg— �7r V WW.ToWN,BREWsTElt.lviA.US TOWN OF BREWSTER ADDENDUM TO DEP SEPTIC INSPECTION REPORT Inspection Location 4 Daisy Zane 56-82 Map &Parcel 5. Is there a 4' separation (1978 code) or a 5' separation (1995 code) Yes V", No Between the bottom of the Soil Absorption System (SAS) and adjusted �.-Oundwater? Tor OF FOUNDATION %res Aola itv ri ok) F40 047 Iq of S.A.S. Batt❑mof S.A.S. Amt. of Stone= _ Ad'usted Cnvundwater 0.o� F I, .o Observed Groundwater 6. Town r (� or Private Well } Distance om nearest septic system component: 7. Wetlands or surface water within 100' of septic system? Yes No ►/ Distance from nearest septic system component; 8. Groundwater flow direction. 10,Z,7 9, Type Of pipe used in system: PVC --v/ Orangeborg Other 10; Sanitary tees or baffles in place ( Yes _ No- NIA?) l Septic tank inlet g Septic tank outlet iel— Pump chamber inlet ry49 D -Box inlet if pumped system Grease trap inlet N � Grease trap outlet „ray F isers -1978 code within 12 inches of grade on septic tarn Risers —1995 code within d inches of grade on all components N® One inspection port on SAS (1995 code) 2 OXS.7 SITZ Z Mot to* Seale � , 1. NO HERBICIDES TO BE USED ON SUBJECT LLAT. 2. UMTS OF CONSTRUCTION ANDIOR GRADING TO BE AS SC14tJfJLHC1tr5E gyp. SHOWN ON PLAN AND SHALL BE VISIBLY MARKED, PRIOR ri TT TO, AND DORING CONSTRUCTION. 3. HAYBALES OR FABRIC SILTFENCE TO BE SECURELY STAKED IN 0� PLACE PRIOR TO CONSTRUCTION AND SHALL REMAIN IN -- PLACE UNTIL DISTURBED AREAS HAVE BEEN REVEGETATED. CD EDGE OF WETLAND 71 4. DISTURBED AREAS SHALL BE STABILIZED AND REVEGETATED AS SOON AS PRACTICABLE UPON COMPLETION OF GRADING. 5. ALL EXCESS EXCAVATED MATERIAL SHALL BE STOCKPILED TOP OF BANK TO THE EAST OF THE EXISTING BUILDING AND SHALL BE q� -'�� \ t REMOVED FROM THE SITE UPON COMPLETION OF CONSTRUCTION. "po EDGE OF WETLAND d 6. ANY ADDITIONAL WORK BEYOND THE SCOPE OF THAT WHICH i \ IS SHOWN HEREON, AND WHICH IS WITHIN 100 OF THE I WETLAND, WILL REQUIRE CONSERVATION COMMISSION EDGE OF POND —� > _ APPROVAL. �4ssr s a_p .24 'Ra7lCel 59 ICP 326-25 14 50' FROM TOP OF SANK/EDGE OF WETLAND ABANDONED,xTING SPOOLS TO BE SPUMPED DR AND i FILLED WITH CLEAN SAND. t t SCIZ 01ho se IiLj ! '�' ,' 1.00' FROM TOFF OF BANK/EDGE OF WETLAND j Pond � 1 I 1 t / i ✓ f i �- /' i / � 5'���O �r�.�� � TOP OF C. 3. F ND r, tI 11 I / / // // / i r®��, %�� Water e1ev. = 28_.3' (5/00) 1i I I I f� :�/ /� ii �� �� / �. ELEV.= 60.00 V J I I > f' .-.• 'BREAKOUT" 1 (ASSUMED DATUM) t I 1,50 S-T.zt CONTOUR X''" .01 F��TUE Cj PO Co �-'" j RESERVE\C,� 1 r` / � r 58.57. r , LA NE Test doze location —��— Existing contour 0 o Q Septic tank ,p chamber y S17 7Z — Distribution boy --j------------- { 4f7 , X IfA? ' X L— e Absorption C$.L�C} bel ® _ Prep i I- .�t4 / SJ / J � 10 Z7 ff L--------___-_ --- --- system4 h Concrete bound — meter seruice Ryder ileo , Inc.. I? E P L 65' t� „ 3Cid is Hill i - � s So. Orleans, , ., 02662 Scale: f--30' 'Tel. (6708) :26-6 – 831A;? Dra wn 6 y CJR Via.. x 50,9 .240-.2306 Date JUAIZ 8, 2000 6 S eet oL'7'.tf o. 7,9 49 a oQdew is" 1. S I L BE: YER:� 50 0-5 H -P. OR APPROVED 4: PUMP SHALL BE EQUIPPED WITH AN AUDIO AND VISUAL ALARM in accordance t, "Commonwealth , ecalt1 o � �, ate zs sties at t - -- . I T T IN TALL D IN A BUILDING a 0 PROVIDE EQUATE WARNING IN CASs=. o aav� a� � al tectioa�, 31x7 C' .R � t�'e�. ; the State 1'�titt��' a;'ort€�, LOCAL° AND SHALL BE LE OF PASSING A LEAS 1_25 S E I 1 T F PUMP FAILURE. R SHALL BE PO "RED BY A CIRCUIT �'xte 5:-_ stt.� ia-e s �- t' Sitan�g COt to :l• ctzo SOLD AT A DISCHARGE TE OF 575 GPM � 21_ I�Hi O iI a_U E aazr zoa o {az-ste Se e Twat alis sal SystemsSEP TE FROM THE PUMP POSER. and tta .7'o of tar Regulations 5�2. ,SUMP SkALL BE INSTALLED IN STRICT CONFORMANCE WITH .t MANUFACTURER'S SPECIFICATIONS. _ ,�. �o tr's or water .�.aes tzar to exist aarat}aan e'a�a� a?i: of t5_ CHECK VALVE, AUTOMATIC CONTROL Ahff� CONTROL BOX S�-aALL BE proposed leaching stem All wells known to ez st within 150 , `. of the AS SPECIFIED BY PUMP NUFACTURER. st are shown. .5. PUMP CONIPOLS SHALL BE MOISTURE PROOF AND OPERATE IN � c �� THE FOLLOJI�'G SEOUEi�iCE: 6_ CONTRACTOR SHALL PRESSURE TEST FORCE IslA1N TO ASSURE or to back ling com eted s ste , ti t Fng er �ata� t Board o f � WATERT GH`TNESS. taltk ,3�or -iction. vi engineer Zf-kour (' im) notice ,dor i s ctio� A) PUMP OFF 0. Contractor shall be _responsible for location o all underu B) PUMP ON 7. IT IS RECOMMENDED ENDED THAT A SLIDE RAIL SYSTEM BE INSTALLED tilities r to excavation. C) ALARM OSI TO FACILITATE REMOVAL OF PUMP FOR INSPECTION ANIS 4ny c s to this plan must be appmved by the Board of Heath, €MAINTENANCE. 5 .Lot zs served by Town water. T�J .t T.d� TCIT a 'ot to scale Tank to be instaded on to level, THRUST BLOCKING SHALL BE stable base (min -6- sto base) PROVIDED AT ALL BENDS TO PREVENT DISRUPTION OF PROPER FUNCTIONING fNCTIONING OF LINE. Trp a7 slab 20 � DIA_ COVER 7 .Zf�" 1Jira. cover .2aJ"" I>ia � TO WITHIN 6'> OF to 'ttain 6 in.. 1I �e rs FINISH GRADE 1e21 = 63 06 tB - � o f ��zzsiz €ae / % � � ':h Ina_ 1Fl" irz 113' 0 run 6.41.0D ;� Ie' NEMA 4X to be 19 rf _ JUNCTiON BOX BLEEDER 2 ^ DIA_ FORCE CAIN m ,�� o ` � � ` zo ti CHECK S0 PSC E en �'d'JTS' 'I1v`6 15€?® I zJ ZAL VE �� Inv. I GATE = 15 �t 64.42 CapacityE s;3 76 r UAL VE 6� 25 ` c �1 ��eozTa . `E EE or scizeri.40 a � O �# � *PROVIDE INLET TEE t `° =------------------------ P. l' ( eT fFgAt of c EZ_ AP OQED PUMP O EXTENDING TO I- -66 " 53 6 S EC aAL. 27' ABOVE OUTLET t E�'T_ Tat zf PUMP OFF 'Vo gar6agge s 8" (SUMP) 674.00 d with this esti oa < _ .: tt lev = 4R 15 *CONTRACTOR SHALL tube � �` VERIF' LOCATION OF 411 tees shaZZ be cast irvn— Afaintain a maxzmum of 36"cozier over ALL EXISTING WASTE or sc a- �fi P V G P-Lpe or 1000 -GAL. SEPTIC TANK SHALL BE all s3estem co s. All components PIPES PRIOR RQ cast- in cone te, UT6LiZED• PNST4LL ON A LEVEL. s ll co7a,o fo s i�caztzo coatai a - t INSTALLING TAN�CS. .a ,�. .��-�,.-,�,..��.�.'�t _-. E ...,aSE_ � G .sTt?a� B,�SE, - _ _ �rr JO TT 1-1 J 4 'T BACKS LL TIGHTLY i iC3 PREVENT SEEPAGE :F SURFACE WATER. (6700_ C,4L. „�C PJB .QST° UVITS, OR .L) mot to scale F? a� e 3XW°'-1 I/. ' utile e 6780 wase sto �t p 1 7 Mini zea of r1) zi to s inspection co r stonerTyp , plT�r1 T % regui al' r unit IV Umber o be€rooms 3 T' L.J /o Win• lud -'sti tett dazly eff nt . 6 1 top s iota stair' I'otral leaching a as as sett s -------- ----------- ---------�-------------- k Sidewall: cl'L� z = 236' FF. o P 3 P L pPk � p� E E , a � _ �° g sn Zeaacizing Capacity as sed 6�` �t$zfe T T ' d . vent loading to - li_ 56 6.P..t.�/5'F) s°. a a m ars E c --------------------------- -------------------J tlis EII D - EE II S ' ewall- 0 56 a- 236 = t32 2 a iE °� Bottom = 6.c? 00 ?. 66 ? J 67. Bottom- 0.56 z 564 = 715.8 66.5 A4' aaiaa . L MI L T 7f �4 a✓ _ r3-6' S.rO. s) (,4r UVfT ' F13' OF -TOVE Z .- , ){'3 6' SJ0_FSJ . 6677 LQ �'L"C'1"L' 6' s 0�ta' _ Sit loch 7 LOAMY ' Z" ' .IDTH _ 12' ZY = 57.3 , LOAMY SA ND I 6,Z 6 SA LSSJ V✓ Z,4TJ TSrF_T_FV , NO C'2 LOAM 60.4 60. z FINE MEDIUM / ULIJ )1 1 , I I ��s.; ND C2 TO FIDE , 7 573 Rya'sr so ; Inc., , J_ Z ? .P 11 rnr SILT (. o water encountered) Cli s3 dd a -mill J�i'c. Date o lam ` X1112000 � ��� SAND C aT1S T h "INE So. rleoz 3 ` 56 ` - .5, .r. , ��� �' �S Gid. -C C'� LOAMY � ;T,.� .I�.I'r . - 1�.�-.al IBJ.. LOAM Tel 6708 255-8312 Drawn by CJR SAND. 53.0 - ` .J .` -.' T.' .PTT T .. °. Ia 2 — X306 tai a , �'ar 0 Job 9. O Town of Brewster 2198 MAIN STREET BREWSTER, MASSACHUSETTS 0263 1-1 898 PHONE: 508.896.3701 EXT. 1120 FAX: 508.896.4538 brhealth Brewster -ma. ov W W W.BREWSTER-MA.COV AGENDA ITEMS UPDATE October 20, 2021 5. Update on Brewster positive COVID-19 numbers a. Brewster active cases and trends b. Age demographics c. Vaccination rates Health Department Amy L, von Hone, R.S., C.H.O. Director Sherrie McCullough, R.S. Assistant Director Tammi Mason Senior Department Assistant 6. Flu Clinic Update a. Brewster Annual Drive-Thru Flu Clinic on 10/15/21 b. Totals: 236 (High Dose: 178 Regular Dose: 58) c. Clinic operated as an Emergency Response Dispensing Drill d. Homebound residents to be scheduled (COA, VNA) e. Schools 7. Discussion on BOH Priority Topics a. Establish list of topics to prioritize b. Assign lead BOH member for established topic c. Discuss possible additional liaison positions related to priority topics Compiled by Amy von Hone, Health Director N:11-IealthlSOH Meeting Notes\BOH Hearing NoteslBpH Hearing Nuaes 10.20.21.doex Oi m u cri 1 0 0 u L W A� W L z N 0 N r -I L (U 0 a--+ U 0 0 0 OQ U L C 0 u C 0) i 0 u cu Z 4-- 0 C D 0 u _a a Ln CD Ln Ln Ln 'S M m N b -4 H LnO 9T/OT-01/07 61OT-E/OT Z/OT-9Z/6 SZ/6-6T/6 8116-71/6 TT/6-5/6 b/6 -6Z/8 8Z/8-ZZ/8 TZ/8-51/8 tiT/8-8/8 LIS -TIS T£1L-5ZIL t,Z/L-BTIL WL-TTIL OTIL-VIL £IL-LZ19 9Z/9-OZ/9 6T/9-ET/9 ZT/9-9/9 S/9-OE/S 6Z/S-£Z/S ZZ/S-9T/5 5T/5 -6/S 8/S-ZIS T/S-SZ/b Wt -81/t, LTIb-T11ti OT1t?-tilt, EIS-gz1E �, LZ/E-TZ/£ Oz/E-till£ ET/E-L/E 9/E-szlz C LZ/Z-TZ/Z � Oz/z-VT/z 75 E1/z_Llz 91z-1EIT OE/1-bZ/T EzIT-L1/7 �, 9T/T-OTIT v 61T-E/T v ZIT-LZ/ZL 9Z/ZT-OZ/ZT 6T/ZT-ET/ZT E Z1/ZL-9/Z1 S/ZT-6Z/TT, sz/TT-ZZ/TT o TZ/11-5T/11 J t,T/T1-8/1T L/TT-T/TT TE/61-5Z/ol t,Z/6T-ST/OT LT/flT-TT/OT a OT/OT-b/OT VOT-LZIG 9216-DZ/6 6T/6-ET/6 c ZT/6-916 S/6-pc/8 6Z/8-EZ/8 = ZZ/8-9T/8 ST/5-619 818-Z18 T/8-9Z/L SZIL-611L 811E-ZT/L TT/L-5/L tl/L-SZ/9 LZ/9-TZ/9 OZ/9-VT/9 ET/9-L19 9/9-T£/S OE/S-bZ/5 EZIS-LT/S 97/5-OT/S 615-£/5 Z/S-9Z/b SZ/tl`61/b 131/t,-ZT/V T1/i7-S/17 rlv-6Z/E aZ/E-ZZ/E WE -STI£ abir �w • . �rt y i� iiNN momr i 1 Ln CD Ln Ln Ln 'S M m N b -4 H LnO 9T/OT-01/07 61OT-E/OT Z/OT-9Z/6 SZ/6-6T/6 8116-71/6 TT/6-5/6 b/6 -6Z/8 8Z/8-ZZ/8 TZ/8-51/8 tiT/8-8/8 LIS -TIS T£1L-5ZIL t,Z/L-BTIL WL-TTIL OTIL-VIL £IL-LZ19 9Z/9-OZ/9 6T/9-ET/9 ZT/9-9/9 S/9-OE/S 6Z/S-£Z/S ZZ/S-9T/5 5T/5 -6/S 8/S-ZIS T/S-SZ/b Wt -81/t, LTIb-T11ti OT1t?-tilt, EIS-gz1E �, LZ/E-TZ/£ Oz/E-till£ ET/E-L/E 9/E-szlz C LZ/Z-TZ/Z � Oz/z-VT/z 75 E1/z_Llz 91z-1EIT OE/1-bZ/T EzIT-L1/7 �, 9T/T-OTIT v 61T-E/T v ZIT-LZ/ZL 9Z/ZT-OZ/ZT 6T/ZT-ET/ZT E Z1/ZL-9/Z1 S/ZT-6Z/TT, sz/TT-ZZ/TT o TZ/11-5T/11 J t,T/T1-8/1T L/TT-T/TT TE/61-5Z/ol t,Z/6T-ST/OT LT/flT-TT/OT a OT/OT-b/OT VOT-LZIG 9216-DZ/6 6T/6-ET/6 c ZT/6-916 S/6-pc/8 6Z/8-EZ/8 = ZZ/8-9T/8 ST/5-619 818-Z18 T/8-9Z/L SZIL-611L 811E-ZT/L TT/L-5/L tl/L-SZ/9 LZ/9-TZ/9 OZ/9-VT/9 ET/9-L19 9/9-T£/S OE/S-bZ/5 EZIS-LT/S 97/5-OT/S 615-£/5 Z/S-9Z/b SZ/tl`61/b 131/t,-ZT/V T1/i7-S/17 rlv-6Z/E aZ/E-ZZ/E WE -STI£ V) c . 0 V V 1 0 D u v u c v v Q) +j V I OJ m 0 txov 9 o m W � m � T o N � CL :3 o L tw�o Q a O - 0 N C ❑ U 0 0 u XI, N CL L Qi 00 Q c N C U a 0 u 110 L N 0 U 0 1 0 r -I cu 0 U r.1 LJ V 1 0 U 0 1 m L v 0 U Lel L L L LL L L y (v w w (U Q� w 0) 12 tO T T A T A 7• T � m N m CY L? 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Abutter Deadline: 10 19 Date: 10/1/2021 TOWN OF BREWSTER 2198 MAIN STREET BREWSTER, MA 02631 PHoNF: (508) 896-3701 Exf 1120 FAX: (508) 896-4538 BRHEALTHnf3RE W STER-MA.GOV W W W.BREW STER-MA.G0V R'TmE LTWDfPAR1 i`VV ST � rel=: PAS �u Application for Board of Health Variances Min --House Local Upgrade Approval ❑Public Hearing SUBJECT PROPERTY ADDRESS. 34 Winslow Landing Road Map: 90 Parcel: 63 Book: 3ZW9�- Page:;e3 LC Certificate: LC Plan: Lot: 63 Name of Applicant: Paul Dal Mailing Address: P.O. Box 178, Brewster, MA 02631 Telephone # 508-221-7080 Email: pmdaley178@gmail.com Owner(s) of Record : Paul H. Daley & Mitzi G. Daley .400'2%961 .f e"4t 4— 4,'/ IWA& ,*X16"a't Mailing Address: P•O. Box 178, Brewster, MA 02631 Design Engineer/Sanitafian: John M. O'Reilly, P.E„ P.L.S. Firm/Company Name. J.M. O'Reilly & Associates, Inc. Mailing Address: 1573 Main St., P.D. Box 1773, Brewster, MA 02631 Telephone #: 508-896-6601 Email address: joreilly@jmoreillyassoc.com Sig natu, - . <! ff ?7 4, App t or Engineer New Construction ❑ Voluntary Upgrade ❑Addition/Alteration W Failed system ❑ Rea l Estate Transfer ❑ Design flow of existing system: 330 Design flow of proposed system: 300 Total sewage flow of site: 330 Conservation Commission approval required: yes ❑ no 10 Order of Conditions/Det. Of Applicability attached ❑ Reason for failure: leach pit does not leach Total lot size (sf): 26,000 sf Date of ConCom hearing: List of all Variances from State and Local codes add sheets if needed TITLE 5 Sec. #:. Description of Variance(s) 3p C,*2 75".LZ f fj SAS Depth Below Grade: 54" of cover provided; 18" variance requested Approved by: Heaith Department nd -I 7.1;11 N:IHealthlBOH regsllnHouse Septic Local Upgrade Approval 201%Varianceapplication FINAL NONF1LLABLE FORM 12.18.19.docx CERTIFIED MAIL RETURN RECEIPT REQUESTED BREWSTER IN-HOUSE SEPTIC LOCAL UPGRADE APPROVAL NOTICE: Date: 1011/2021 Re: 34 Winslow Landing Road Map: 90 lot: 63 Subject Address Dear Abutter: Please be advised that an application for septic local upgrade approvals from the regulations of the Massachusetts Department of Environmental Protection, Title 5 and/or the Town of Brewster Regulations for Subsurface Disposal of Sewage, has been submitted to the Brewster Health Department for approval. The following variances are requested: List of all variances from State and Town Codes Title 5, Sec # ti Description of Variance(s) JjnerV 1E; Zzl SAS Depth Below Grade: 54" of cover provided; 18" variance requested Brewster Reg. # Description of Variance(s) The application and plans are available for review and comment at the Brewster Health Department, Brewster Town Offices, 2198 Main Street Brewster, Monday through Friday (excluding holidays) from 8:30 a.m. to 4:00 p.m. Sincerely, A p p I ica nt/Rep resentative CC: Brewster Health Department N-.\Health\BOH regs\InHouse Septic Local Upgrade Approval 201 9\i nhousevarianceah u tternotif [cation NONFILLABLE FORM 12.11.19.docx Certified by: pi8111 ov, wsr fes/ 04 $r TOWN OF BREWSTER, MA a : BOARD OF ASSESSORS Jamas M. Gallagher. MAA o " L w 2198 Main Street Brewster, MA 02631 Deputy Assessor � o* IfiG Abutters List Within 65 feet of Parcel 90/6310 96r19r6 73 WIN OW. LANDI G -RG 8016WO 90120 ELSON. STRE T 901 3 WNSL W, LAN I G ROAD INSLOW. DING R ❑ 9D166/D 61 N LSON, STREET 90117M 6 WINSLOW. LANDING RO D 9016510 31 N LSCCu STREET 63 9611 BIO 34 W1 SL ;'IAN ING A INSLOW LANDING R r- 96115M 96!6410 35 INSLOW. LANDIN R 27 MAIN. STREET BW2110 26 AIN. ST EET 8 N IN.ST14 100 13 1 QQ ft 671 MAlN. STRE Key Parcel ID Owner _ L=atiy MlailingStreel Maling City ST ZipCdlCouNry 1436 89.19.0-R BAIER ME RID ITH TRUSTEE 2663 MANN STREET 2663 MAIN STREET BREWSTER MA 02831 (1452) CLARMAR TRUST 1435 89.20.0-R BROTHERS GARY & SHIIRLEY TRUSTEES 2871 MAIN STREET 21 WORMWOOD STREET BOSTON MA 02219 (14.55) CID TKC INVESTMENTS, LLC APT. 402 1434 89-21-0-R N 8 N REAL PROPERTIES LLC 2669 MAIN STREET 34 RUSSET ROAD BREWSTER MA 02631 (1450) 1413 90 -i5.0 -R BAERGA LOUIS A&ANDREAC 35 WINSLOW LANDING ROAD P O BOX 687 BREWSTER MA 02831 (1436-1) 1414 90.16.0-R PARSONS ADRIENNE ATRUSTEE 0 WINSLOW LANDING ROAD 1:579 PINE RME DRIVE HOLLY MI 48442 (1436.2) THE TRUST OF ADRIENNE A PARSONS 1415 90.17.0-R MOLASKEY JAMES P TRACEY ATRUSTEE: 53 WINS LOW LANDING ROAD 109 WINTERGREEN LANE GROTON MA 61450 (14363) MOLASREY FAANLY 2020 LIVING TRUST 1417 90.18-0-R MCBRIDE WHITNEY T & LINDA 65 WINS LOW LANDING ROAD 291 NW RED BARN CIRCLE SENTONVII-LE AR 72712 (14.36.8) UNIT 1 1418 90.19-0-R POLLARD JOHN M TRUSTEE 73 WINSLOW LANDING ROAD P 0 BOX 1195 BREWSTER MA 02831 (1436.7) POLLARD HANCYATRUSTEE 1419 90.20.0.13 DICKEY MARGARET PEARL & 87 WINSLOW LANDING ROAD P O BOR 559 BREWSTER MA 02631 (14.37) REMY JANE M CO TRUSTEES 1416 90.63-0-R DALEY PAUL H & MITZI G TRUSTEES 34 WINSLOW LANDING ROAD 31 NELSON STREET BREWSTER MA 031 (1436.5) DALEY 1NVESTMENT REALTY TRUST 1480 90-64-0-R ERING CHARLES E & YVONNE 1 2705 MAIN STREET P O BOY, 349 BREWSTER MA 02631 (14.97) 143$ 93-65-0-R DALEY PAUL H & MITZI G TRUSTEES 31 NELSON STREET 31 NELSON STREET BREWSTER MA 02631 (14-09) DALEY REALTY TRUST i 1481 9UM-R DALEY PAUL H & MITZI G TRUSTEES i! 61 NELSON STREET 31 NELSON STREET BREWSTER MA 02631 (14.99) DALEY INVESTMENT REALTY TRUST 1421 90-67-" HAWLEY Mr HAEL TRUSTEE 83 NELSON STREET CIO GW & WADE WELLESLEY MA 02461 (14-39) THE MICHAEL HAWLEY TRUST • 93 WORCESTER STREET 1011/2021 Page 1 89-19-0-R 89-20-0-R BROTHERS GARY & SHIRLEY TRUSTEES BAIER MERIDITH TRUSTEE C/O TKC INVESTMENTS, LLC CLARMAR TRUST 21 WORMWOOD STREET 2663 MAIN STREET APT. 402 BREWSTER, MA 02631 BOSTON, MA 02210 90-15-0-R 9G-1 6-0-R PARSONS ADRIENNE A TRUSTEE BAERGA LOUIS A & ANDREA C THE TRUST OF ADRIENNE A PARSONS P O BOX 687 15678 PINE RIDGE DRIVE BREWSTER, MA 02631 HOLLY, MI 48442 90-18-0-R 90-19-0-R MCBRIDE WHITNEY T & LINDA A POLLARD JOHN M TRUSTEE 291 NW RED BARN CIRCLE POLLARD NANCY A TRUSTEE UNIT P0BOX 1195 BENTONVILLE, AR 72712 BREWSTER, MA 02631 90-63-0-R 90-64-0-R DALEY PAUL H & MITZI G TRUSTEES DALEY INVESTMENT REALTY TRUST ERING CHARLES E & YVONNE 1 31 NELSON STREET P O BOX 349 BREWSTER, MA 02634 BREWSTER, MA 02631 90-66-0-R 90-67-0-R HAWLEY MICHAEL TRUSTEE DALEY PAUL H& MITZI G TRUSTEES THE MICHAEL HAWLEY TRUST DALEY INVESTMENT REALTY TRUST CIO GW & WADE 31 NELSON STREET 93 WORCESTER STREET BREWSTER, MA 02631 WELLESLEY, MA 02481 89-21-0-R N & N REAL PROPERTIES LLC 34 RUSSET ROAD BREWSTER, MA 02631 90-17-0-R MOLASKEY JAMES & TRACEY A TRUSTEES MOLASKEY FAMILY 2020 LIVING TRUST 109 WINTERGREEN LANE GROTON, MA 01450 90-20-0-R DICKEY MARGARET PEARL & REMY JANE M CO -TRUSTEES P O BOX 558 BREWSTER, MA 02631 90-65-0-R DALEY PAUL H & MITZI G TRUSTEES DALEY REALTY TRUST 31 NELSON STREET BREWSTER, MA 02631 Lf} C3 Lr) 1 s. 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CLARMAR TRUST .... r'- APT. 402 .. I r- 2663 MAIN STREET BOSTON, MA 02210 f .... . BREWSTER, MA D2&31 E v 0 C U7 m co Town of Brewster 2198 MAIN STREET BREWSTER, MASSACHUSETTS 02631-1898 PHONE: 508.896.3701 EXT. 1120 FAX: 508.896.4538 brhealth rt)bre~vster-ma_n.• WWW.13REWS111'R-MA.0 OV Health Department Amy L. von I lone,. R.S., C.H2O. Director Sherrie McCullough, R3. Assistant Director Tammi Mason Senior Department Assistant Notice of Board of Health Variance Approval/Deed Restriction October 17, 2021 Paul H. Daley Mitzi G. Daley P.O. Box 178 Brewster, MA 02531 RE: 34 Winslow Landing Road, Brewster, MA Map: 90 Parcel: 631 Book:34532 Page: 20 Owner of Record: Matthew R. and Kristina M. Eldredge Dear Mr. and Ms. Daley: On October 17, 2021, the Brewster Health Department reviewed and approved the following variance for the septic system upgrade at the above address per engineered plans by JM O'Reilly and Associates, Inc. dated September 28, 2 02 1, last Revised October 4, 2021. Title 5: 310 CMR 15.221 (7) (General Construction Requirement for All System Components) a. 1.5' variance,4.5' of final fill over Distribution Box and Leach Facility . Town of Brewster: None In granting the above variance, the Health Department imposes the following Order of Conditions: 1. The property consists of an existing three (3) bedroom dwelling. No additional bedrooms allowed without further review by the Board of Health. 2. Prior to issuance of the Certificate of Compliance this Variance Approval Letter must be properly recorded at the Barnstable County Registry of Dees and a recorded copy of same shall be furnished to the Brewster Health Department as proof of the recording. 3, Variances shall expire within one (9) year of the date of this approval. Please feel free to contact me if you have any comments or questions on the above. I can be reached at the Health Department, 508-895-3701, ext. 1120. Sincerely, p�m4L��VaolnHon:e, R. S,, C.H.O. `6irector of Health cc: JM O'Reilly and Assoc.., Inc. P.O. Box 1773, Brewster, MA 02631 File N:\Health\BOH Decision Letters\Septic Variance In -House Detisions\Tltle S Brewster Approvals\34 Winslow Landing Rd InHouseApprovaI 10.17.2021.doc Town of Brewster 2198 MAIN STREET BREWSTER, MASSACHUSETTS 02631-1898 PHONE: 508.896.3701 EXT, 1120 FAX: 548.896.4538 brhealth@brewster-ma.gov W W W.BRE W STER-MA.GOV AGENDA ACTION ITEM FORM BOH Variance Agenda Item ❑ In -House Local Upgrade Approval N Other: ❑ Health Department Amy L. von Hone, R. S., C.H.D. Director Sherrie McCullough, R.S. Assistant Director Tammi Mason Senior Department Assistant Board of Health Meeting Date: Consent Agenda Project Location: 34 Winslow Landing Road Map & Parcel: 90/63 Owner's Name & Address: Paul Daley P.O. Box 178 Brewster, MA 02631 Applicant: Paul H. Daley & Mitzi G. Daley, P.O. Box 178, Brewster, MA 02631 Date Requested: October 5, 2021 Title 5 Variance Request: Yes N No ❑ Board of Health Variance Request: Yes❑ NOM Click here to enter telt. Other: Yes N No ❑ 1. Outside Zone II and existing Town water 2. Upgrade of existing failed Title 5 system (1987) servicing existing 3 bedroom dwelling Health Director's Recommendation: Approve with following comments and conditions 1. The existing property consists of an existing 3 bedroom dwelling serviced by town water and a 1987 Title 5 septic system (1000 gal Septic Tank, Leach Pit). The applicant proposes to upgrade the system to a Maximum Feasible Compliant Title 5 septic system. The proposed septic system will consist of the existing 1000 gal septic tank,proposed distribution box, and a 25' x 12.83' x 2' Leach Chamber system for a maximum 3 bedroom capacity septic system. 2. Due to the existing depth of the main sewer line exiting house foundation and the depth of the existing septic tank, the leach facility will be greater than 3' below the final grade. N:1Hea1[h1B0H Meeting NoteslBOH Hearing Notes134 Winslow Landing Road M9OP63 Age nda.Variance Action Item Form 10.20.202 1. docx 3. The following variance is requested: Title 5: a. 1.5' variance, proposed 4.5' of final fill over the SAS facility Town of Brewster: none 4. Approval with the following conditions: a. Approve the septic variance as requested above with the following conditions: i. There will be no addition of the number of bedrooms in the residential structure without further BOH review. A copy of the BOH Approval Letter to be recorded at the Barnstable County Registry of Deeds prior to issuance of the Certificate of Compliance upon completion of the septic system installation. A copy of the recorded letter to be placed on file at the BOH. ii. Variance will expire one (1) year from the date of the BOH Approval. N:1Healft!30H Meeting Notes\BOH Hearing Notes134 Winslow Landing Road MWP63 Agenda.Variance Action Item Form 10.20.2021.docx GENERAL TES: S1 L TEST LOGS: TEST HOLE 1: EL=49.3± A.) NEITHER DRIVEWAYS NOR PARKING AREAS ARE ALLOWED OVER SEPTIC SYSTEM UNLESS H-20 COMPONENTS ARE USED. B.) THE DESIGNER WILL NOT BE RESPONSIBLE FOR THE SYSTEM AS DESIGNED UN- LESS CONSTRUCTED AS SHOWN. ANY CHANGES SHALL BE APPROVED IN WRITING. C.) CONTRACTOR SHALL BE RESPONSIBLE FOR VERIFYING THE LOCATION OF ALL UNDERGROUND AND OVERHEAD UTILITIES PRIOR TO COMMENCEMENT OF WORK. DEPTH FROM SURFACE (INCHES) SOIL HORIZON SOIL TEXTURE (USDA) SOIL COLOR (MUNSELL) SOIL MOTTLING OTHER 0-18 A FINE LOAMY SAND 10YR 3/2 NONE 18-36 B FINE LOAMY SAND 10YR 5/8 NONE 36-58 C1 LOAMY FINE TO MED SAND 10YR 5/8 NONE FIRM 58-68 C2 SILT LOAM 10YR 6 1 NONE FIRM 68-127 C3 LOAMY MED. TO CRS. SAND 10YR 4/3 NONE 15% GRAVEL- 5% COBBLES C STmuk,TI TES° TEST HOLE 2: EL=49.4± 1.) ALL CONSTRUCTION SHALL CONFORM TO THE STATE ENVIRONMENTAL CODE, TITLE 5, AND THE REQUIREMENTS OF THE LOCAL BOARD OF HEALTH. 2.) SEPTICTANK(S), GREASE TRAP(S), DOSING CHAMBER(S) AND DISTRIBUTION BOX(ES) SHALL BE SET ON A LEVEL STABLE BASE WHICH HAS BEEN MECHANICALLY COMPACTED, OR ON A 6 INCH CRUSHED STONE BASE. 3.) SEPTICTANK(S) SHALL MEET ASTM STANDARD C1127-93 AND SHALL HAVE AT LEASTTHREE 20" DIAMETER MANHOLES. THE MINIMUM DEPTH FROM THE BOT11 - DEPTH FROM SURFACE (INCHES) 0-24 SOIL HORIZON A SOIL TEXTURE (USDA) FINE LOAMY SAND SOIL COLOR (MUNSELL) 10YR 3/2 SOIL MOTTLING NONE OTHER 24-47 B FINE LOAMY SAND 10YR 5/8 NONE 47-63 C1 I FINE LOAMY SAND 10YR 5/8 1 NONE 63-78 C2 BOG IRON 10YR 3/1 1 NONE VERY FIRM 78-104 C3 SILT LOAM 10YR 6/1 NONE FIRM 104-152 C4 LOAMY MED. TO CRS. SAND 10YR 413 NONE 15% GRAVEL; 5% COBBLES TOM OF THE SEPTIC TANK TO THE FLOW LINE SHALL BE 48 . 4.) SCHEDULE 40 PVC INLET AND OUTLET TEES SHALL EXTEND A MINIMUM OF 6" DATE OF TESTING: 9-16-2021 ABOVE THE FLOW LINE OF THE SEPTIC TANKAND SHALL BE INSTALLED ON THE PERCOLATION RATE: LESS THAN 5 MIN/INCH IN C3 LAYER OF TH1 AND C4 LAYER OF TH2. CENTERLINE OF THE TANK DIRECTLY UNDER THE CLEANOUT MANHOLE. WITNESSED BY: MATT WROBEL, EIT, J.M. O'REILLY & ASSOCIATES, INC. AMYVON HONE, HEALTH DIRECTOR 5.) RAISE COVERS OF THE SEPTIC TANK AND DISTRIBUTION BOX WITH PRECAST NO WATER ENCOUNTERED CONCRETE WATERTIGHT RISERS OVER INLET AND OUTLET TEES TO WITHIN 6" OF USEA LOADING RATE OF 0.74 GPD/SF FOR SIZING OF SOIL ABSORPTION SYSTEM. FINISH GRADE, OR AS APPROVED BY THE LOCAL BOARD OF HEALTH AGENT. 25.0' 6.) PIPING SHALLCONSIST OF 4" SCHEDULE 40 PVC OR EQUIVALENT. PIPE SHALL BE LAID ON A MINIMUM CONTINUOUS GRADE OF NOT LESS THAN 1%. 4.0' 8.5' 8.5' 4.0' 7.) DISTRIBUTION LINES FOR SOIL ABSORPTION SYSTEM (AS REQUIRED) SHALL BE 4' DIAMETER SCHEDULE 40 PVC LAID AT 0.005 FT/FT. LINE SHALL BE CAPPED AT END OR AS NOTED. 8.) OUTLET PIPES FROM DISTRIBUTION BOX SHALL REMAIN LEVEL FOR AT LEAST 2' BEFORE PITCHING TO SOIL ABSORPTION SYSTEM. WATER TEST DISTRIBUTION BOXTO ASSURE EVEN DISTRIBUTION. q v 9.) DISTRIBUTION BOX SHALL HAVE A MINIMUM SUMP OF 6" MEASURED BELOW THE OUTLET INVERT. ro m 10.) BASE AGGREGATE FOR THE LEACHING FACILITY SHALL CONSIST OF 3/4" TO N4 1-1/2" DOUBLE WASHED NATIVE STONE FREE OF IRON, FINES AND DUSTAND SHALL BE INSTALLED BELOW THE CROWN OF THE DISTRIBUTION LINE TO THE BOTTOM OF THE SOILABSORPTION SYSTEM. BASE AGGREGATE SHALL BE COVERED WITH A 2" LAYER OF 1/8" TO 1/2" DOUBLE WASHED NATIVE STONE FREE OF IRON, FINES AND DUST. 11.) VENT SOIL ABSORPTION SYSTEM WHEN DISTRIBUTION LINES EXCEED 50 FEET, WHEN LOCATED EITHER IN WHOLE OR IN PART UNDER DRIVEWAYS, PARKING AREAS, TURNING AREAS OR OTHER IMPERVIOUS MATERIAL, OR WHEN PRESSURE DOSED. 12.) SOILABSORPTION SYSTEM SHALL BE COVERED WITH A MINIMUM OF 9" OF CLEAN MEDIUM SAND (EXCLUDING TOPSOIL). 13.) FINISH GRADE SHALL BE A MAXIMUM OF 36" OVER THE TOP OF ALL SYSTEM COMPONENTS, INCLUDING THE SEPTIC TANK, DISTRIBUTION BOX, DOSING CHAMBER SCALE: 1" =10' I AND SOILABSORPTION SYSTEM. SEPTIC TANKS SHALL HAVE A MINIMUM COVER OF 9". 14 rFROM THE DATE OF INSTALLATION Of -THE SOIL ABSORPTION SYSTEM UNTIL RECEIPT OF A CERTIFICATE OF COMPLIANCE, THE PERIMETER OF THE SOIL ABSORP- TION SYSTEM SHALL BE STAKED AND FLAGGED TO PREVENT THE USE OF SUCH AREA FOR ALLACTMITIES THAT MIGHT DAMAGE THE SYSTEM. 15.) EXISTING 1,000 GALLON SEPTIC TANK: THE INSTALLER SHALL REMOVE EXISTING TEES WITHIN THE TANK. NEW TEES WITH OUTLET GAS BAFFLE SHALL BE INSTALLED. THE DIMENSIONS OF THE TEES SHALL BE AS SHOWN ON FLOW PROFILE. 16.) EXISTING LEACH PIT: THE EXISTING LEACH PITSHALL BE PUMPED FILLED AND ABANDONED OR REMOVED. 17.) SOIL REMOVAL: ALLTOPSOIL, SUBSOIL, LOAMY FINE SAND, SILT LOAM AND BOG IRON (REFER TO SOIL LOGS) SHALL BE REMOVED FOR A DISTANCE OF 5 FEET FROM THE SOIL ABSORPTION SYSTEM (SAS) AND DOWN TO THE LOAMY MEDIUM TO COARSE SAND. THE EXCAVATION SHALL BE BACKFILLED WITH CLEAN "TITLE 5" SAND, COMPACTED TO MINIMIZE SETTLEMENT. 18.) LOCATION OF EXISTING LEACH PIT WAS TAKEN FROM THE AS -BUILT CARD ON FILE WITH THE BREWSTER HEALTH DEPARTMENT. INSPECTION NOTE: PRIOR TO FINAL INSPECTION BY TH E ENGINEER, SYSTEM N EEDS TO BE COMPLETE INCLUDING BUILDUP FOR COVERS. FLOW PROFILE: TOTAL OF FOUR(4) COVERS TO WITHIN 61NCHES OF FINISH GRADE; NOT TO SCALE TWO ON SEPTIC TANK, ONE ON D -BOX AND ONE ON SAS 20 DIAMETER CONCRETE COVERS RAISED TO WITHIN 6" OF FINISH TOP OF FOUNDATION GRADE (OR AS NOTED) EL= (SEE NOTE#5) Proposed EL= SAS PLAN VIEW 0 EXISTING 1,000 GALLON SEPTIC TANK TO REMAIN DB -3 D -BOX H-20 EXISTING I PROPOSED KITCHEN & I """" DINNING BR#1 D UNINGROOM FIRST FLOOR (NTS) BATH STORAGE ATTIC HALL BR#3 I BR#2 / Brewster, E 101. MA 14,. NG SEWAGE DESIGN FLOWi 3T 3 BEDROOM DWELLING @ 110 GPD = 330 D T 4`0" GAS BAFFLE - EXISTING 1,000 GALLON SEPTIC TANK TO REMAIN DB -3 D -BOX H-20 EXISTING I PROPOSED KITCHEN & I """" DINNING BR#1 D UNINGROOM FIRST FLOOR (NTS) BATH STORAGE ATTIC HALL BR#3 I BR#2 / Brewster, MA SYSTEM DESIGN C LCULATI S: SEWAGE DESIGN FLOWi 3 BEDROOM DWELLING @ 110 GPD = 330 D LEACHING CAPACITY REQUIREM3 BEDROOMS MAX. @ 110 GPD = 330 D REQUIRED SEPTIC TANK CAPACITY REQUIREM DAIL F W = PD 20 = 660 AL. REQUIRED SEPTIC TANK CAPACITY PROVIDEDi 4Route EXISTING 1,000 GALLON SPETIC TAN TO REMAINLEACHING CAPACITY PROVIDEDi in street ONE 1 2. LEAH G CHAMBER CAN L CH:Vt=[(25.0 X 12.83) + (25.0 X 2.0)2 (12.83X2.0)2]X0.7 GPD/SF=349.3GPD 349GPD>330GPD EQUIRED NOTE: A GARBAGE DISPOSAL I NOT PERMITTED WI THIS DESIGN_ INSTALD ONE (1)- 3 OUTLET DISTRIBUTION BOX (H-20 Rate TWO (2)-500 GALLON LEA CHAMBERS WITH 4' F NATIVE STONE ALLAROUND toa NOT TO SCALE tL 48.5 00 CD 48.3 PLAN BOOK 268 PAGE 73 48.3 °o DEED BOOK 32293 PAGE 163 •5 m ASSESSORS' MAP 90 PARCEL 63 ca a so 3 Utility Pole LEGEND 48.4 EXISTING CONTOUR " 48.3 PARCEL63 32 PROPOSED CONTOUR X1234 EXISTING SPOT GRADE AREA= 26,000 SF± 24x5 PROPOSED SPOT GRADE 48. 48.5 (PER ASSESSOR'S RECORDS) - Nq___ WATER SERVICE LINE -o- OVERHEAD UTILITY SERVICE 6 -U- UNDERGROUND UTILITY SERVICE 48.5 Existing O� - G- GAS SERVICE LINE Gravel Driveway 48.3 01 TEST HOLE / BORING LOCATION ST SEPTICTANK 48.4 48.3 DB DISTRIBUTION BOX 1.0 49.0 8.7 48.5 SAS SOILABSORPTION SYSTEM ® Reserve RESERVED FOR FUTURE 48.4 487 UTILITY POLE \,48.8 x 48.8 -Shed CATCH D CATCH BASIN FIRE HYDRANT R WELL �% Op x 48.8 x 48.7 DRAINAGE MANHOLE 48.9 : "' ■ CONCRETE BOUND, FOUND _ x 49.1 49. - ._ - - - -- - - TOP -OF BANK-- LIMIT ANK LIMIT OF WORK -- 49.5 FENCE 01�'I//(/ X 49.4 49.5 x 49.6 EDGE OF CLEARING NT 49.4 `Q® NOTE: THIS PLAN IS INTENDED FOR USE AS A SEWAGE SYSTEM 0 x 49.2 qj 0 --- PLAN AND DOES NOT REPRESENTA PROPERTY BOUNDARY o L,� c,� 'ic `- 49.1 SURVEY. THE PROPERTY SHOWN HERE ON IS THE PARCEL a°, TP DBOX 49.5 - „'o a �o� DESCRIBED IN DEED BOOK 32293, PAGE 163. a 2 =V m�\� am O x 49.6 yy 49.6 �� �� -N2 Jap r x 5 .1 �h �4� } �o 49.5 w TH1 `� f' ,to a . G�5 X49.5' ; 11 LP 050.0 x 49.0 SECOND FLOOR (NTS) "' 12" Maples ,. x 49.5 y FLOOR PLANS 16" Maple x 4 4 50.9 51.3 �10' Pine 12" Maple 11 50.2'. 51.2 50 PROPOSED VENT f 36 MIN 3± 50.4 , ti, Permit valid for REPAIR OF SEPTIC SYSTEM ONLY, due to State and Local septic variances. Board of Health review and 49.5 approval is required for any future additions/renovations/alterations x 49.1 to sewage facilities and/or structures/dwelling. I Brewster Health Department JL40 Existing 1,000 Gallon Septic Tank pR TO REMAIN -17�*s Inlet Invert EL=45.5± 6 � -- Outlet Invert EL=45.3± 4OKarne Date VARIANCE REQUESTED: _ 52"±Proposed 45.0± SOILABSORPTION DEPTH BELOW GRADE: 54 INCHES OF COVER PROVIDED; 18 INCH VARIANCE REQUESTED 2" LAYER OF 1/8"-1/2" NATIVE STONE 44.00 0 '� 3/4"-1-1/2" NATIVE STONE OF�� 44.23 2" DROP 42.00 OTA EiLLY USE TWO (2) SHOREY PRECAST c 4 V CIVIL 500 GALLON LEACH CHAMBERS 5.3`± NO. Se 00 Both Runs WITH 4' OF NATIVE STONE AROUND -11'± LEACHINGvCHAMBER -EL=36.7± BOTTOM OF TEST HOLE 0 2�1 NAL 60 25.0'x 12.83'x 2.0' (H-20 RATED UNITS) SCALE 1"=20' G-.\AAJobs\Paul Daley\9169\dwg\9169SDS Plan.dwg REVISED 10 4-2021: ADED VENTTO S.D.S DALEY INVESTMENT REALTY TRUST PAUL DALEY, TRUSTEE, P.O. BOX 178, BREWSTER, MA 02631 SITE & SEWAGE DISPOSAL SYSTEM DESIGN 34 WINSLOW LANDING ROAD, BREWSTER, MA J.M. ' EIUY & ASSOCIATES, INC. Professional Engineering & Land Surveying Services 1573 Main Street - Route 6A P.O. Bos 1773 (508)896-6601 Office Brewster, MA 02631 (508)896-6602 Fax I t: SCALE: BY: CHECK: JOB NUMBER: 9-28-2021 1 As Noted I jmo I JMO I JMO-9169 �������u1111tu�E+ullrr���r'��, Town of Brewster � 11 °W'2198 BREWSTETtMA SACHUfN 5ETT5 fl2631 I898 Health Department Amy L. van Hone, R.S., C.H.G. Director PHONE: 508.896.3701 EXT. 1120 1 0 FAX: 508.896.4538 Sherrie McCullough, R.S: brhealth(@brewster-ma.go Assistant Director •'��RPQRATo 1` W WW.BREWSTER-MA.GOV TartSenior DeI i Mason Assistant 6'a IP II/III/Ill 1;i111131i111111110\ `��r CHECK LISF NOTES FOR NEW FOOD SERVICE OPERATION DATE ce) Cit OPERATOR 11 1L CONTACT INFORMATION !r G U NAME. LOCATION & TYPE OF OPERATION �[la CGL a G I - [II -X — 'teI[ ► SEPTIC SYSTEM INFO: CAPACITY/ COM PONENTSJINSP ECTION LrL1� hi k,(t u 6r IIi TT fi C �5 6L A NUMB R OF SEATS, 113 WATER.SOURCE f LW4 ANNU__jr _EASONAL HOURS OF OPERATION FLOOR PLANS_,k S SITE PLAN MENU �j1_� CONSUMER ADVISORY C� L ALLERGEN AWARENESS Q PRODUCT LIST FOR RETAIL OPERATION CERTIFIED FOOD MANAGER CERT c[ 11 MjQ ALLERGEN AWARENESS CERT 7 1 d C ANTI CHOKING CERT IF OVER 25 5 ATS l i) EQUIPMENT SPECS 5L�O I IkO TYPE OF WAREWASHERJTYPE OF SANITIZER1®+iq r c WHAT SANITIZER WILL BE USED FOR CLEANING 110_1N , HAND SINKS �2_� MOP SINK �1 �� THREE -BAY SINK_ PREPSINK.1 NUMBER & TYPES OF REFRIGERATOR & FREEZER UNITS ICE MACHINE if/s WASTE REMOVAL VAS BATHROOM FAC LI IfIES C. l`.-_ DRY STORAGE � FOLLOW-UP NEEDED WITH: BUILDING rk ZONING0�._ PLANNNYNG SELECTMAN O�- FIRE POLICE '�L CONSERVATION �. COMMENTS- FINAL INSPECTION DATE d -U f Lie A - REVIEW SIGN OFF 64ttkCz ( TSN' DATE N:: HealthlMcCulloughlFOODILettersTood reviewsWew Food Establishment Check List.doc Town of Brewster 2198 MAIN STREET BREWSTER, MASSACHUSETTs 0263 1-1 89 8 PHONE: 508.896.3701 EXT. 1120 FAX: 508.896.4538 brheatth ,br-P), sten-int�,,g2v W W W.BREW STER-MA.GOV F52021- dB N Health Department Amy L von Hone, R.S., C. H.O. Director Sherrie McCullough, R.S. Assistant Director Tamrni Mason Senior Department Assistant Food Establishment Permit Application . - (Application must be submitted at least 30 days before the planned opening date) 1. Establishment Name; THE KT t 2, Establishment Address: 2 io7 l N1 q i Mfr T 3. Establishment Mailing Address (if different); Email address; 21 worm'W t a2 022.1+ n llt_ aNZ'Ca h,6+mal ca 4. Establishment Phone #; -1 -7 4 - a23. oZ 1414 5. Applicant Name &Title; Dgnle' 1t Pahzrc 0WNER- .6. Applicant Address: .6. Zi war n 2 BLISTON MA 12Z2,10 7. Applicant Phone # 24 Hour Emergency #: . q 52- 8. Owner Name & Title (if different from applicant): 9. Owner Address (if different from applicant); 10. Establishment Owned by: ❑ An association XA corporation ❑ An individual ❑ A partnership ❑ Other legal entity 11. If a corporation or partnership, give name, title and home address of officers or partner Name Title Home ddress _ l\PaV Z1'OCA, a W Nff 2,1 Wormwoo 5 �?D UN �Y 21 \V O L KIWOM—S 12. Person directly responsible for daily operations (owner, person in charge, supervisor, manager, etc.) noLymfle- Name & Title; Address: Tele hone: - Email address: Emergency Phone #: 13. Water Source (town or well water) A-pW�A 14. Sewage Disposal: �)<ritle 5 system n Internal Grease ❑ 'Grease trap interceptor 7 Town of Brewster 2198 MAIN STREET BREWSTER, MASSACHUSETTS 02631-1898 PHONE: 508.896.3701 EXT. 1120 FAX: 508.896.453 8 .brhealth(c Brewster-ma.Rov WWW.BREW STER-MA.GOV Food Establishment Plan Review Packet To be used for: New Establishments ❑ New Owners ❑ Renovated or Altered Establishments ❑ Change in Use Incomplete packets will not be accepted Health Department Amy L. von Hone, R.S., C.H.O. Director Sherrie McCullough, R.S. Assistant Director Tammi Mason Senior Department. Assistant R IVSD 5EP 2 2 2021 BREWSTER HEALTH t)EPAR l MENT Name of Establishment TfH�5 KIT k -M Location of Establishment 2611 MAIM STM7F Contact Person/Title Phone# 'Domelle WIVI-Z(Coct - oww - s2- ` q r Projected Start of Project: Desired Opening Date:. it r r 12dZ 1 Category: restaurant ❑ Institution o Retail Food o Other: Type of Service (check all that apply): ❑ Sit down meals — number of meals XfAeals to be served .(check all that apply): Areakfast)<'Lunch XDinner jK Take Out j"Catering ❑ Mobile Vendor ❑ Retail food — total square footage ❑ Residential Food Please include the following documents: '* &In 1 (0-1 ldA1*'Z A1404x, )A- prC'I,p l (P(('h1v 11�1�20�1 ID�DUM''� Office Use Onl Pro osed menu (including seasonal; off-site and banquet menus) Manufacturer Specification Sheets for each piece of ecluipment shown on plan Vl--Site VJ plan showing location of business in -building: location of building onsite including alleys, streets: and location of any outside a ui ment (dum psters, septic sstem — if applicable) Plan drawn to scale of food establishment showing location of equipment, plumbing, electrical services and mechanical ventilation (see next page) Completed review packet Food Preparation Review Food Supplies: 1. Are all food supplies from inspected and approved sources? xYes ❑ No 2, What are the projected frequencies of deliveries for: Frozen foods: Zit per u3'e Refrigerated foods: 2��a Dry good: 7_C De C_ 3. Provide information on the amount of space (in cubic feet) allocated for:. Dry storage: Refrigerated storage: Frozen storage: 4. How will dry good be stored off the floor? . S 5 t 9 kS Cold Storage: 1. Is an adequate freezer and refrigeration available to stare frozen food at or below 0' and refrigerated foods at 41° or below? Xyes R No 2. Will raw meats, poultry and seafood be stored in the same refrigerators and freezers with cooked/ready to eat foods? XYes ❑ No B. if yes, how will cross -contamination be prevented? 4. Does each refrigerator/freezer have a thermometer? �(Yes ❑ No 5. is there a bulk ice machine available?Yes in No Cooking: 1, Will food product thermometers be used to measure final cooking/reheating temperatures of TC5's? its ❑ No 2. List types of cooking equipment Conye`c.rjoV% &V 5ToVj TiAI- Top Cirri ll . Brol ie_r n�ir Hot/Cold Holding: 1. How will hot TC5's be maintained at 135° F or above during holding for service? indicate type and number of hot holding units. i� courd-t'rTop holdrr Urlits 4, How will cooking equipment, cutting boards, counter tops and other food contact surfaces which cannot be Submerged in sinks be sanitized? Chemical type: 1 A') f [ r�� "-C7 l 2-a P $C�[_ 01 Test kit provided: 5. Is there a designated sink for produce washing/food preparation? )(Yes ❑ No 6. Is there a.dishwasher?x[1'es ❑ No Type of sanitization used (hot water or chemical type) Gln Cwt t GaJI Are the temperature/pressure gauges accurately working? KYes ❑ No Are there test kits/papers for checking sanitizer concentration)wYes ❑ No 7. Is there a three -bay sink? )<Yes ❑ No Does the largest pot fit into each compartment of the sink? Ves a No Handwashing/Toilet facilities 1. Is there a handwashing sink in each food preparation and warewashing area? Xyes ❑ No 2. Do all handwashing sinks, including those in the restrooms, have a mixing valve or combination faucet? Y Yes ❑ No 3, Do,self-closing metering faucets proved a flow of water for at least 15 seconds without the need to reactivate the faucet? ❑ Yes ❑ No 4. Is hand cleanser and drying facilities available at all handwashing sinks? Pryes ❑ No S. Are covered waste receptacles available in each restroom? X Yes d No. 6. Is hot and cold running water under pressure available at each handwashing sink?X Yes ❑ No 7. Are all toilet room doors self-closing? xy'es n No 8. Are all toilet rooms equipped with adequate ventilation? Kies ❑ No 9. Is handwashing signage posted in the employee restroom? ;(Yes ❑ No 7, Will air curtains be used? ❑ YesAo If yes, where: Garbage and Refuse 1. Do all containers have lids? K'yes ❑ No 2. Will refuse be store inside? ❑ Yes ❑NO 3. Is there an area designated for can or floor mat cleaning?Yes n No 4. Will a dumpster be used? ❑Xes a No Number of dumpsters: *2— Size of dumpsters: Frequency of pick up: Contractor: S. Will there be outside garbage cans? L(rYes n No 6. Describe surface and location where dumpster and garbage cans will be stored av u -e t r) Sec aF B La rti S 7. Describe location of grease storage receptacle BpcC'k� OF TqE but I D 8. Is there an area to store recycled containers? 9(yes ❑ No If yes, location: Q CLC 07 s General: 1, Where will cleaning agents be stored? • rM / r1 :'M 2, Are insecticides/rodenticides stored separately from cleaning and sanitizing agents? Yes ❑ No location: 3, Area all containers of toxics clearly labeled. ❑ N�s ❑ No 4. Location of clean linen storage: Z) S. Location of dirty linen storage: __ Cctl<7�'''��-- 1 H C a r d �A N z w w 40 104 v U N 6j°' _ �o 0 U 40 t - G° 4 w w 40 v U N � aw +� 0 U C.) .. °? ' v j Q v LL N a�0 �� r1� w t J w w 40 Ln N w V z z I KA w W14 1 Q 0 U N Z n. R. uj o to o W tt . ^e � OuN7 rn �+ Cd �� aW t4-, o 1-4 U 1 QZo 0¢U{ � � F^NCT} o Z�Q 00 0 o to o tt . ^e � d N 0 a'i U Lz LLJ Q �� El LL- HW d m Urn -qI Cn CI] 1 `� rFs pq � C 0 d o o L w � t; C f] N c z iL' CD � �i � o E � e L-; ; Q o '- Lr; od o = N CD A --iu m � red 7 a -� V ZE � mac" F4 -a a q x "� w� 6 wm0 � �� o �- a— � aj c � C vi car+ � o U � � aCL' V) w b V o6 Li 0 22 to R}mJ ti d p ry �' _ '�' ! a '�r1 `a Ca ' o '�' s a rp+i fvi -! ' fY7 c� w , D LU W 'L a� t�ry �rai 2pq_ ,� �N E _°tia' �0 �5 + � �� N aldpq a a a• CL ` Ct 'OQ fy a E� a= sic .ae L-11 69 53 r n o tp t`oo e d IV rn o yd U 40 15 wfc o 0 0 c%J1 con H7 a 3 °; _ § -1 t Q:l t7 a Q 9 t3 a o;,.; = as o ao J M r - di w� Omcai5 15 G t7 a H a Ln Ln CU 2 -54R m _ C a a rri in D� kJ OL u pp r m tiLq a IF a °=; 1.2 CIO 0 cc LD Qn to 13 a tj } 6 c ' m R LR O EO .c W *,''� a� ` of v, HE o yR a L v a_— p v Cca H �a ° L W��_ p off �Z a d� ry W • G ,li o r Ol 0 7 ❑ C 4 m m m CA w a CA c,�,� �n tm Lna►12.`C a i - A LU us 3 a LA M o vai '� 2 o '" p ` c 3 0 = 06 if LEI LIX t�0 43 L, vl d N w' rami if a m ud O r; v H .0 v � 4 m _ E _ x J C J Q r / J Q ,.r[d \ j o 0 4- 0 J �." �. m ") ao 7_ rn In _ � ii r_ rn 2 v � 4 m _ E _ x J C J Q r / J Q ,.r[d \ j o 0 4- 0 J 1 ARCHITECTURAL ASSOCIATES 145 South Street Boston, MA 02111 T 617.357.7171 www.beaconarch.com © 2021 JDT Investments, LLC 21 Wormwood, Suite 402 Boston, MA 02210 PROJECT KITCHEN CAFE BREWSTER 2 671 MAIN STREET, BREWSTER MA JOB NUMBER 20-814 SCALE 1/2 If = 1 '-0" DRAWING NAME Kitchen Equipment & Basement Plan DRAWING NO. ISSUE DATES DATE BY 05-14-2021 • DESCRIPTION • Permit Set JDT Investments, LLC 21 Wormwood, Suite 402 Boston, MA 02210 PROJECT KITCHEN CAFE BREWSTER 2 671 MAIN STREET, BREWSTER MA JOB NUMBER 20-814 SCALE 1/2 If = 1 '-0" DRAWING NAME Kitchen Equipment & Basement Plan DRAWING NO. J.M. O'Reilly & Associates, Engineering & Land Surveying Servief 1573 Main Street, 2nd Floor, P.O. Box II) Brewster, MA 02631 (508) 896-6601 Fax (508) 896-6602 Department of Environmental Protection DATE Attn: Title 5 Program 1 One Winter Street, 5th Floor Routine Inspection Form Boston, MA 02108 Shipping Method: Regular Mail ❑✓ Federal Express Lab Results Certified Mail El UPS Priority Mail F-� Pick Up Express Mail F-1 Hand Deliver Inc. OCT 14 2021 BREWSTER HEALTH DEPARTMENT DATE: 10/01/2021 39 McGuerty Road Brewster, MA 02631 LETTER .OF SMITTAL JOB NUMBER: 8248BW COPIES DATE DESCRIPTION 1 09/10/21 Routine Inspection Form DEP Approved Inspection Form Lab Results For review and comment: � For approval: As Requested: For your use: 0✓ REMARKS: cc: John M. O'Reilly, P.E., P.L.S. Board of Health Client From: GJB If enclosures are not as noted, kindly notify us at once FIELD INSPECTION & SERVICE REPORT FASTo wastewater treatment systems INSTALLATION AUTHORIZED SERVICE PROVIDER Installation Address 39 McGuerty Road NameJ.M. O'Reilly & Associates, Inc. Owner Name Lowell & Susan Outslay Street 1573 Maln Street, Brewster, MA Mail Address 39 McGuerty Road city Brewster state MA zip 02631 Mail Address P.O. BOX 1773 city Brewster State MA Zip 02631 Phone 508-237-2106 Fax e-mail susanbaker715@gmail.com Phone 508-896-6601 Fax 508-896-6602 e-mail gbrehm@jmoreillyassoc.com INSTALLATION INFORMATION Model No. Serial No. Date of Installation Date of last pumpout MicroFast 0.5 Unknown unknown unknown EQUIPMENT YES NO MAINTENANCE PERFORMED AND COMMENTS Electrical Panels System is operating correctly mechanically. Visual Alarm Operating x Audio Alarm Operating ifpresent)X Blower(s) Air Inlet Filter Clean x Blower Hood Vents Clear x Excessive Noise x Excessive Vibration x Treatment Unit(s) Unusual Odor x Effluent samples collected for lab analysis. Pum out Required: Primary Settling Zone x taken 6-10-21 Aerobic Treatment Zone x EFFLUENT(options) LIMIT RESULT Effluent quality passed field testing. Estimated Daily Flow pH (Standard Units) 6-9 S.U. 7.0 1 Alkalinity = 120, NO3 = 2.0, NO2 = 0.0, NH3 = 6.0 Color Clear Clear Temperature 73.76 F Odor Slightly Musty odor Musty (not septic) DO= 3.0 mg/L Turbidity= 12.50 NTU OWNER SIGNATURE TEC GNATURE SERVICE DATE 09/10/2021 .� Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. rah Massachusetts Department of Environmental Protection Bureau of Resource Protection - Title 5 DEP Approved Inspection and O&M Form for Title 5 I/A Treatment and Disposal Systems A. Installation Lowell & Susan OL Owner 39 McGuerty Road Facility Street Address Brewster Mailing address of owner, if differeht: Street Address/PO Box: City State (508) 237 - 2106 ext. Telephone Number B. Authorized Service Provider J. M. O'Reilly & Associates, Inc. O&M Firm 1573 Main .Street 02631 Zip Zip Street Address Brewster MA 02631 City State Zip (508) 896 - 6601 ext. Telephone Number Greg Brehm Certified Operator Name C. Facility/System Information BREW-McG039-FAS Bio-microbics DEP ID Manufacturer ID unknown Installation Date 16149 Certification Number unknown Start of Operation Approval Type: E General ❑ Provisional ❑ Piloting Seasonal Residence — used less than 6 mo./year: ❑ Yes D. Operating Information 09/10/2021 Inspection Date taken 6-10-21 Sludge Depth (to be checked yearly) Microfast 0.5 Model Number ❑ Remedial E No 06/10/2021 Previous Inspection Date Pumping Recommended ❑ Yes E No t5aiom.doc • rev. 04-11-13 Page 1 of 3 LlMassachusetts Department of Environmental Protection Bureau of Resource Protection - Title 5 DEP Approved Inspection and O&M Form for Title 5 I/A Treatment and Disposal Systems E. Field Testing Field Inspection: Color: ❑ gray ❑ brown ® clear ❑ turbid ❑ Other (specify): Odor: ® musty ❑ earthy Effluent Solids: ® no ❑ some ❑ moldy ❑ offensive ❑ turbid pH 7.0 SU DO 3.0 rng/L Turbidity 12.5 NTU 6 to 9 2 or greater 40 or less Should a Remedial or General Use system fail the Field Testing, effluent samples shall be collected per Standard Methods and analyzed for BOD and TSS. F. Sampling Information Samples Taken: ❑ Influent ® Effluent Commercial systems or systems with a design flow of 2000 gpd and greater, and General Use nitrogen reducing systems: gpd Parameters sampled: ❑ pH ® BOD ❑ CBOD M TSS ® TN ❑ Other (list below) see lab results Other 1 Other 2 Other 3 G. Inspection and Maintenance Description of any maintenance performed since previous inspection & during this inspection: System is operating correctly mechanically. Notes and Comments: System is showing signs of maturing and improvement from first and second visit. t5aiom.doc • rev. 04-11-13 Page 2 of 3 Massachusetts Department of Environmental Protection Bureau of Resource Protection - Title 5 DEP Approved Inspection and O&M Form for Title 5 I/A Treatment and Disposal Systems H. Certification I certify: I have inspected the sewage treatment and disposal system at the address above, have conducted the required Field Testing and/or sample collection in accordance with Standard Methods, have completed this report and the attached technology operation and maintenance checklist, and the information reported is true, accurate, and complete as of the time of the inspection. I am a Massachusetts cer i5ed ope�ator in accordance with 257 CMR 2.00. 10/01/2021 Operator Signat" re Date System owner must submit this report, technology O&M checklist, and any required sampling results to the local board of health as follows for each inspection performed: Remedial Use — by January 31St of each year for the previous calendar year Piloting Use - within 45 days of inspection date Provisional Use — by March 31th of each year for the previous 12 months General Use — by September 301h of each year for the previous 12 months Send to: Department of Environmental Protection Attention: Title 5 Program One Winter Street, 5th Floor Boston, MA 02108 t5aiom.doc • rev. 04-11 -1 3 Page 3 of 3 EAWROTECH LABORATORIES, INC. MA CERT. NO.: MMA 063 8 Jan Sebastian Drive Sandwich, MA 02563 (508)888-6460 1-800-339-6460 FAX (508)888-6446 Thursday, September 34, 2021 r ' A JJVI.. O'Reilly &Associates, Inc. Su leDate �� �z �; t. " l ��, j09/ 0/21 1.173 Main St., PO Box 1773 r i Comments; E �� �. � f: %r fl 39,McGuertyRoad Brewster Brewster, MA 02631 Parameters Proje&Name: Outslay Comments: Project Number: 8248BW Sampled By: GB Lab Order Number: WW -212134 Date Received: 09110121 Sarriple T3'Pele'Mie 35 Ment, r ' A Samp Su leDate �� �z �; t. " l ��, j09/ 0/21 r i Comments; E �� �. � f: %r fl 39,McGuertyRoad Brewster Parameters Units Test Results Reportable Limits Date Analyzed Analyst Method BOD 5 -Day mg/L 27 2.0 09/10/21 CLM SM 5210 B Kjeldhal Nitrogen mg/L 21 0.60 09/21/21 MS/KB M4500-Norg B= Nitrate -N mg/L 9.30 0.01 09/11/21 SD EPA 300.0 Nitrite -N mg/L 0.528 0.006 09/11/21 SD EPA 300.0 Total Nitrogen mg/L 31 NA 09/27/21 MS/KB Calculation Total Suspended Solids mg/L 6.01 1.5 09/30/21 CF/MS SM 2540 D All samples were analyzed within the established guidelines of US EPA approved methods with all requirements met, unless otherwise noted at the end of a given sample's analytical results. We certify that the following results are true and accurate to the best of our knowledge. BRL=below reportable limits 'see attached By: Ronald J. Saari Laboratory Director Page 1 of 1 S' r j� 3 O CD cn o a O Q c4jn m =4 °1 C. ca CD 41 -, a CD o w 4km �' w z Cc, rL 'U o o C _ 55 00 O0 c D o� N y y c�D —� _ N 0o 4 w D 'd ao w f�E a Q • ID c n m m N W CDy W X4 t9 'V W O O z W O m a o o w z O D WCD (D C N W C. O n � � N r J.M. O'Reilly & Associates, Engineering & Land Surveying Services 1573 Main Street, 2nd Floor, P.O. Box 177 Brewster, MA 02631 (508) 896-6601 Fax (508) 896-6602 Department of Environmental Protection u DATE Attn: Title 5 Program 1 One Winter Street, 5th Floor Routine Inspection Form Boston, MA 02108 Shipping Method: Regular Mail ❑✓ Federal Express ❑ Certified Mail ❑ UPS ❑ Priority Mail ❑ Pick Up ❑ Express Mail n Hand Deliver n Inc. RECEIVED OCT 14 2021 BREWSTE_R HEALTH DEPARTMENT DATE: 10/06/2021 200 Brier Lane Brewster, MA 02631 LETTER OF SMITTAL JOB NUMBER: 8206W COPIES u DATE DESCRIPTION 1 09/10/21 Routine Inspection Form DEP Approved Inspection Form Lab Results For review and comment: ❑ For approval: ❑ As Requested: ❑ For your use: Y] nL�n�w w. cc: John M. O'Reilly P.E., P.L.S Board of Health J & R Sales and Service, Inc. Client From: MJW If enclosures are not as noted, kindly notify us at once FIELD INSPECTION & SERVICE REPORT FAST@ wastewater treatment systems INSTALLATION AUTHORIZED SERVICE PROVIDER InstallationAddress200 Brier Lane NameJ•M. O'Reilly &Associates, Inc. Owner Name Jack and Nancy Drake Street 1573 Main Street, Brewster, MA Mail Address P.O. BOX 939 city Brewster State MA zip 02631 Mail Address P.O. Box 1773 city Brewster State MA zip 02631 Phone 508-896-5984 Fax e-mail jackdrake200@comcast.net Phone 508-896-6601 Fax 508-896-6602 e-mail mwrobel@jmoreillyassoc.com INSTALLATION INFORMATION Model No. Serial No. Date of Installation Date of last pumpout MicroFast 0.5 8/6/19 unknown ffUnknown EQUIPMENT YESNO MAINTENANCE PERFORMED AND COMMENTS Electrical Panel(s) System is operating correctly mechanically. Visual Alarm Operating X Audio Alarm Operating x if resent (s) -Blower Air Inlet Filter Clean X Blower Hood Vents Clear X Excessive Noise X Excessive Vibration X Treatment Units Effluent quality passed field test Unusual Odor x Effluent samples collected for lab analysis. Pum out Required: Primary Settling Zone X 6" sludge, .25' scum Aerobic Treatment Zone X 6" sludge, 0" scum EFFLUENT(options) LIMIT RESULT Alk = 40, NO3 = 3.0, NO2 = 0, NH3 = 0.5 Estimated Daily Flow H (Standard Units) 6-9 S.U. 6.5 Color Clear clear Temperature 72.86 F Odor Slightly Musty odor Earthy (not septic) DO= 4.0 mg/L Turbidity= 3.49 NTU OWNER SIGNATURE TECH - CIAPJX = IG ATURE SERVICE DATE 09/10/2021 Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. tab Massachusetts Department of Environmental Protection Bureau of Resource Protection - Title 5 DEP Approved Inspection and O&M Form for Title 5 I/A Treatment and Disposal Systems A. Installation Jack and Nancy Drake Owner 200 Brier Lane Facility Street Address Brewster City Mailing address of owner, if different: P.O. Box 939 Street Address/PO Box: Brewster MA City State (508) 896 - 5984 ext. Telephone Number 02631 Zip 02631 B. Authorized Service Provider J. M. O'Reilly & Associates, Inc. O&M Firm 1573 Main Street Street Address Brewster MA 02631 City (508) 896 - 6601 ext. Telephone Number John O'Reilly Certified Operator Name State C. Facility/System Information BREW-Bri200-FAS Bio-microbics DEP ID 8/6/19 Installation Date Approval Type: ❑ General Manufacturer ID 17746 Certification Number 8/6/19 Microfast 0.5 Model Number Start of Operation ❑ Provisional ❑ Piloting ® Remedial Seasonal Residence — used less than 6 mo./year: ❑ Yes ® No D. Operating Information 09/10/2021 Inspection Date 6" sludge, .25" scum Sludge Depth (to be checked yearly) 2/12/2020 Previous Inspection Date Pumping Recommended ❑ Yes ® No t5aiom.doc • rev. 04-11-13 Page 1 of 3 LlMassachusetts Department of Environmental Protection Bureau of Resource Protection - Title 5 DEP Approved Inspection and O&M Form for Title 5 I/A Treatment and Disposal Systems E. Field Testing Field Inspection: Color: ❑ gray ❑ brown M clear ❑ turbid ❑ Other (specify): Odor: ❑ musty ® earthy ❑ moldy ❑ offensive ❑ turbid Effluent Solids: ® no ❑ some pH 6.5 SU DO 4.0 mg/L Turbidity 3.49 NTU 6 to 9 2 or greater 40 or less Should a Remedial or General Use system fail the Field Testing, effluent samples shall be collected per Standard Methods and analyzed for BOD and TSS. F. Sampling Information Samples Taken: ❑ Influent ® Effluent Commercial systems or systems with a design flow of 2000 gpd and greater, and General Use nitrogen reducing systems: gpd Parameters sampled: ❑ pH ❑ BOD ❑ CBOD ❑ TSS ❑ TN ❑ Other (list below) see lab results Other 1 Other 2 Other 3 G. Inspection and Maintenance Description of any maintenance performed since previous inspection & during this inspection: maintenance completed per manufacturer's checklist Notes and Comments: System appears to be operating correctly at this time. t5alom.doc • rev. 04-11-13 Page 2 of 3 Massachusetts Department of Environmental Protection Bureau of Resource Protection - Title 5 DEP Approved Inspection and O&M Form for Title 5 I/A Treatment and Disposal Systems H. Certification I certify: I have inspected the sewage treatment and disposal system at the address above, have conducted the required Field Testing and/or sample collection in accordance with Standard Methods, have completed this report and the attached technology operation and maintenance checklist, and the information reported is true, accurate, and complete as of the time of the inspection. I am a Massachuser,d4tifi 'O jPerator in accordance with 257 CMR 2.00. 10/06/2021 Operato(Si re Date System owner must submit this report, technology O&M checklist, and any required sampling results to the local board of health as follows for each inspection performed: Remedial Use — by January 31 st of each year for the previous calendar year Piloting Use - within 45 days of inspection date Provisional Use — by March 31th of each year for the previous 12 months General Use — by September 30th of each year for the previous 12 months Send to: Department of Environmental Protection Attention: Title 5 Program One Winter Street, 5th Floor Boston, MA 02108 t5aiom.doc • rev. 04-11-13 Page 3 of 3 ENVIROTECH LABORATORIES, INC. MA CERT. NO.: M AM 063 8 Jan Sebastian Drive Sandwich, M.4 02563 (508)888-6460 1-800-339-6460 -AX (508)888-6446 Tuesday, October 5, 2021 J, M. O`Reilly K Associates, 6te. 1573 Main Sl., PO Box 177.3 Brewster, .MA 02631 ProjectName: Drake Project Number: 8817 Sampled By: Greg Brehm Lab Order Number: WW -212133 Date Received: 09/10/21 Comments: �.: Sctn►nle il'1?a Samp1� 7"enle San►ple Dater s G"niiittturis �r" EA 13:fl0 09/10/21 20U Brier ane �te+f�ster u.ar_ pura111den ~ Units Ted Recalls ReportableLimitti Date Analyzed Analyst Method BOD 5 -Day mg/L 11 2.0 09110/21 CLM SM 5210 B aldhal Nitrogen mg/L 3.6 0.60 09121/21 MS/KB M4500-Norg B Nitrate -N mg/L 27.0 0.01 09/11/21 SD EPA 300.0 Ngrde-N mg/L 0.292 0.006 09/11121 SD EPA 300.0 Total Nitrogen mg/L 31 NA 09/27/21 MS/KB Calculation 7-1 Total Suspended Solids mg/L 4.0 1.5 09/28/21 CF SM 2540 D All samples were analyzed within the established guidelines of US EPA approved methods with all requirements met, unless otherwise noted at the end of a given sample's analytical results. We certify that thefollowing results are true and accurate to the best of our knowledge. BRL=below reportable limits ,'see attached By: Ronald f Saari Laboratory Director Page 1 of 1 a ti O z •y O O U) an d 3 z z d �, U) U m Ln :3 Y L I— L N • O X c i Q o. LL (� ro v O O V o z w — a m c V r Q M v 4 y oa c v = O U Q o � LWL r � O O 4 •� V ao O co L a a coz CD w ��.- :.L w U o 0 jai ev � a > w U d � � � O N 3 3 � U w L Q le Im L O ❑ k O o � U � ro _ o 0 o E b N �. C C a' � Co J.M. O'Reilly & Associates, Inc. Engineering & Land Surveying Services 1573 Main Street, 2nd Floor, P.O. Box 1773 Brewster, MA 02631 (508)896-6601 Fax (508) 896-6602 TO: Brewster Board of Health 2198 Main Street BrcWster, MA 02631 Shipping Method: Regular Mail ❑✓ Federal Express El Certified Mail El UPS ❑ Priority Mail F—] Pick Up Express Mail n Hand Deliver DATE: 10/06/2021 LETTER OF RECEI OCT 14 2021 BREWSTER HEALTH DEPARTMENT 200 Brier Lane Brewster, MA 02631 SMITTAL JOB NUMBER: 8206W COPIES DATE DESCRIPTION 1 09/10/21 Perc-Rite Maintenance Checklist For review and comment: F-1 For approval: F-1 As Requested: F-1 For your use: F✓ REMARKS: cc: John M. O'Reilly P.E., P.L.S Oakson, Inc. Client From: GJB If enclosures are not as noted, kindly notify us at once e � , ROUTINE OPERATION AND MAINTENANCE CHECKLIST FOR PERC-RITE DRIP DISPERSAL SYSTEM Address: 200 Brier Lane, Brewster Homeowner: Drake Residence Operator: Greg Brehm WWTO Lic #:16149 Job #: 8206w Date: 09/10/2021 HISTORICAL DATA and CURRENT READINGS Previous flow meter reading: 17,700 Design flow: 440 Date of last visit: 12/10120 Current flow meter reading: 57,284 Calculated water usage: 39,584 gallons,143.94gpd Start-up dose rate Current dose rate ZONE 1: 2.0 GPM 2.1 GPM ZONE 2: ZONE 3: ZONE 4: FIELD CONDITIONS A. Drip dispersal field: visible wet spots YES ❑ NO p Comments: B. Air release valves: erosion YES ❑ NOD leakage/spraying YES NOD✓ Comments: PUMP CHAMBER/FLOAT OPERATION A. Floats match pin lights in control panel YES[Z] NO❑ Comments: B. Alarm float working YES❑✓ NO[-] Comments: C. Solids or scum present YES❑ NO❑✓ Comments: CONTROL PANEL A. Switches in AUTO position YES M7 NO❑ Comments: B. Peak Level light on YES[-] NO❑✓ Comments: C. Power and Run lights on (microprocessor) YES❑✓ NOD Comments: PUMP and VALVE OPERATION A. Pump in HAND position: flow meter running YES❑✓ NOD Comments: B. Zones 1-4 (one at a time): flow meter running YES 0✓ NO❑ dose rate correct YES D NO ❑ flush rate > dose rate YES NO❑ Comments: C. Disc filter back flushing: working properly YES ❑✓ NO[-] Comments: D. Disc filter inspection: excessive residue YES F1 NOD cleaning required YES [Z] NO❑ Comments: E. Switches returned to AUTO position YES ❑✓ NO ❑ Comments: F. RESET/CYCLE START: functioning properly YES [Z] NO ❑ Comments: G. Hydraulic Unit: leaks, crimps, or other issues YES ❑ NOD Comments: SEPTIC and/or PRE-TREATMENT TANKS A. Examine and clean effluent filter: excessive residue YES EI NO ❑ Comments: N/A B. Septic tank pumping recommended YES ❑ NO ❑✓ 1. Sludge depth: s" 2. Scum depth: 0.25° Comments: C. Service pre-treatment system YES[Z] NO❑ Comments: See77; rt� Operator signature �License No. 16149 6-1 Comments/Observations: System appears to be operating correctly at this time. COASTAL engineering co. TECHNICAL SERVICES 260 Cranberry Highway Orleans, MA 02653 508.255.6511 P 508.255.6700 F Orleans I Sandwich I Nantucket coastalengineeringcompany.com To: James Watt King's Landing Apartments 3 State Street Brewster, MA 02631 Subject: King's Landing Apartments 3 State Street Brewster, MA Permit #934-1 Plans Copy of Letter I OSpecifications Wn mro conrlinc tho fnllnwino itamc- RECEIVED OCT 0 5 2021 BREWSTER HEALTH DEPARTMENT TRANS Date: 10/01/2021 Project No. WBR007.00 Via: ®1st Class Mail oPick up oCertified DFed Ex ®Other Copies Date No. Description 1 08/2021 934-1 Daily Log Sheet 1 08/31/2021 934-1 Quarterly Discharge Report w/Laboratory Test Results 1 08/16/2021 934-1 Monthly Monitor Well Data Report (Field-tested data) 1 10/01/2021 934-1 1eDEP Electronic Receipt These are transmitted as checked below: for approval ®for your use ®as requested for review 6 comment Remarks: Enclosed are the recent reporting forms for the wastewater treatment facility at the above -referenced location. Effluent test results show high levels of Total Nitrogen that exceed the upper discharge limit. We will adjust the system settings and use of process control chemicals to help improve treatment of the system. The average daily flow was approximately 9,984 gpd. Additional parameters sampled: Fecal Coliform — <100 ml If you have any questions regarding this report or the WWTF, please do not hesitate to contact us. cc: Brewster Board of Health By: Chad A. Simmons, WWTPO CC Commission Horsley Witten Group, Inc. AquaPoint.3 LLC NOTE: If enclosures are not as noted, please contact us at (508) 255-6511 D:\DOC\w\wBR\007\TRANSMITTALS\TRANSMITTAL (AUGUST 2021).DOC Orleans I Sandwich I Nantucket -- Massachusetts Department of Environmental Protection 934 Bureau of Resource Protection - Groundwater Discharge Program 1. Permit Number Groundwater Permit Tax identification Number DAILY LOG SHEET 2021 AUG DAILY 3. Sampling Month & Frequency C. Daily Readings/Analysis Information Date Effluent Reuse Irrigation Turbidity Influent pH Effluent Chlorine Uv Flow GPD Flow GPD Flow GPD pH Residual Intensity (mg/1) (%) 1 9820 6.73 7.49 C� 2 110778 6.81 7.40 1 L1 3 10890 �I �- 4 9178 5 11340 6 9285 6.92 7.51 7 7562 l 6.88 7.44 8 10601 9 19262 , 6.93 17.42 L� 10 9446 11 11175 � � IJ I1 Q 12 11165 6.91 7.40 13 10645 6.98 7.46 14 9761 6.96 7.48 15 10888 6.88 7.41 16 10503 6.93 7.44 17 18 10343 Q 19 10970 7.04 7.39 20 10015 6.89 7.41 21 9767 22 9811 7.03 7.44 23 9753 7.04 7.50 24 19518 25 10734 26 10610 6.93 7.44 27 8668 6.94 7.46 28 9290 7.03 7.48 29 10166 7.13 7.51 30 8720 7.11 7.52 31 10112 gdpols.doc • rev. 09/15/15 Groundwater Permit Daily Log Sheet • Page 1 of 1 Massachusetts Department of Environmental Protection 1934 Bureau of Resource Protection - Groundwater Discharge Program 1. Permit Number Groundwater Permit DISCHARGE MONITORING REPORT 2. Tax identification Number 2021 AUG MONTHLY 3. Sampling Month & Frequency D. Contaminant Analysis Information • For "0", below detection limit, less than (<) value, or not detected, enter "ND" • TNTC = too numerous to count. (Fecal results only) • NS =Not Sampled 1. Parameter/Contaminant 2. Influent 3. Effluent 4. Effluent Method Units Detection limit BOD 62 ND 10 MG/L TSS 134 7.5 I 5.5 MG/L TOTAL SOLIDS 14 20 MG/L AMMONIA -N 25.5 MG/L NrrRATE-N 2,2 -- —� 0.10 MG/L TOTAL NITROGEN(NO3+NO2+TKN) 14.71 0.050 MG/L OIL & GREASE ND --`-" 1.0 MG/L infeffrp-blank.doc • rev. 09/15/15 Groundwater Permit Discharge Monitoring Report • Page 1 of 1 L HA ,.A NA LY T1 CA L ANALYTICAL REPORT Lab Number: L2146642 Client: Coastal Engineering Company 260 Cranberry Highway Route 6A Orleans, MA 02653 ATTN: Chad Simmons Phone: (508) 255-6511 Project Name: KINGS LANDING BREWSTER Project Number: WBR007.00 Report Date: 09/08/21 Serial No:09082114:22 The original project report/data package is held by Alpha Analytical. This report/data package is paginated and should be reproduced only in its entirety. Alpha Analytical holds no responsibility for results and/or data that are not consistent with the original. Certifications & Approvals: MA (M-MA086), NH NELAP (2064), CT (PH -0574), IL (200077), ME (MA00086), MD (348), NJ (MA935), NY (11148), NC (25700/666), PA (68-03671), RI (LA000065), TX (T104704476), VT (VT -0935), VA (460195), USDA (Permit #P330-17-00196). Eight Walkup Drive, Westborough, MA 01581-1019 508-898-9220 (Fax) 508-898-9193 800-624-9220 - www.alphalab.com Page 1 of 20 Se ri al_N o: 09082114:22 Project Name: KINGS LANDING BREWSTER Lab Number: L2146642 Project Number: WBR007.00 Report Date: 09/08/21 SAMPLE RESULTS Lab ID: L2146642-01 Date Collected: 08/31/21 08:00 Client ID: INFLUENT (COMPOSITE) Date Received: 08/31/21 Sample Location: 3 STATE ROAD, BREWSTER, MA Field Prep: Not Specified Sample Depth: Matrix: Water '`'xarar. itlA Page 6 of 20 Dilution Date Date Analytical Parameter Result Qualifier Units RL MDL Factor Prepared Analyzed Method Analyst General Chemistry - Westborough Lab Solids, Total 420 mg/1 10 NA 1 09/07/21 07:25 121,2540B DW Solids, Total Suspended 34. mg/I 10 NA 2 - 09/01/21 14:35 121,2540D AC Nitrogen, Ammonia 25.5 mg/I 0.375 5 09/02/21 08:00 09/02/21 22:08 121,4500NH3-BH AT Nitrogen, Total Kjeldahl 29.2 mg/I 1.50 5 09/02/21 12:30 09/03/21 18:34 121,4500NH3-H AT BOD, 5 day 62. mg/I 30 NA 15 08/31/21 23:20 09/05/21 17:22 121,52106 JD '`'xarar. itlA Page 6 of 20 Serial No:09082114:22 Project Name: KINGS LANDING BREWSTER Lab Number: L2146642 Project Number: WBR007.00 Report Date: 09/08/21 SAMPLE RESULTS Lab ID: L2146642-02 Date Collected: 08/31/21 08:00 Client ID: EFFLUENT (COMPOSITE) Date Received: 08/31/21 Sample Location: 3 STATE ROAD, BREWSTER, MA Field Prep: Not Specified Sample Depth: Matrix: Water FiA Page 7 of 20 Dilution Date Date Analytical Parameter Result Qualifier Units RL MDL Factor Prepared Analyzed Method Analyst General ;Chemistry Westborough Lab _ - _ Solids, Total Suspended 7.5 mg/1 5.5 NA 1.1 09/01/21 14:35 -- --- 121,2540D - --- ----------- AC -- --- —-- ------.._...__ Nitrogen, Ammonia — - 9.56 mg/I 0.075 - -- - 1 -- - ------ -- 09/02/21 08:00 09/02/21 22:09 121,4500NH3-BH AT Nitrogen, Nitrite 0.81 mg/I 0.050 1 - 09/01/21 06:29 44,353.2 MR Nitrogen, Nitrate 2.2 mg/1 0.10 1 09/01/21 06:29 44,353.2 MR Nitrogen, Total Kjeldahl 11.7 mg/I 0.300 1 09/02/21 12:30 09/03/21 18:33 121,4500NH3-H AT BOD, 5 day ND mg/1 10 NA 5 08/31/21 23:20 09/05/21 17:22 121,52106 JD FiA Page 7 of 20 Serial No:09082114:22 Project Name: KINGS LANDING BREWSTER Lab Number: L2146642 Project Number: WBR007.00 Report Date: 09/08/21 SAMPLE RESULTS Lab ID: L2146642-03 Date Collected: 08/31/21 08:15 Client ID: POST EQ Date Received: 08/31/21 Sample Location: 3 STATE ROAD, BREWSTER, MA Field Prep: Not Specified Sample Depth: Matrix: Water Page 8 of 20 Dilution Date Date Analytical Parameter Result Qualifier Units RL MDL Factor Prepared Analyzed Method Analyst General Chemistry - Westborough Lab Nitrogen, Nitrate 4.9 mg/I 0.10 1 09/01/21 07:15 44,353.2 MR .... . _. _...__ _..... ........... . .......... — _... _ - . Nitrogen, Total Kjeldahl 16.7 .......... mg/I _ 0.300 1 09/02/21 12:30 09/03/21 18:38 121,4500NH3-H AT Page 8 of 20 Fl N d' r sip6 N 00 p 5 O Z � ; o � R i 1 W . J. miL G]' coy t,ON Isoos R v Sal � w �J zop Q I EL Q Lit- I 0 U L. 0 E gV.s fl p 9 4 1 i 1 O T miL gV.s CON fl p eHN 4 1 i 1 miL G]' coy t,ON Isoos R 1 Sal � Z. zop Q I O. R pip LU G ti E 0 F r Q CL CL 00 • T fL S c 0 CL OL CON p eHN 4 1 i 1 miL G]' coy t,ON Isoos 1 Sal � :1 zop Q I S1,9009 R pip LU c. ti Q CL CL 00 IE fL An 0 OL G- u 5 - .V-. d�.'S { YG Q m� a d 4 1 1 miL G]' 1 1 � � a Q a R pip LU c. CSC 00 IE Q m� a d a miL �. Gl E � a Q pip LU c. CSC 00 IE fL OL G- u 5 - .V-. d�.'S { YG ENVIROTECHLABORATORLES, INC. -AL4 CERT. NO.: MMA 063 8 Jan Sebastian Drive Sandwich, MA 02563 (508)888-6460 1-800-339-6460 FAX (508)888-6446 Tuesday, September 28, 2021 Coastal Engineering Co. 260 Cranberry 1-fighway Orleans, M4 02653 ProjectlVaine. Kings Landing Comments. Project Alumber. WBR007. 00 Sampled IV: C.Simmons Lab Order Number. WW -212030 Date Received. 08131121 All samples were analyzed within the established guidelines of US EPA approved methods with all requirements met, unless otherwise noted at the end ofa given sample's analytical results. We certify that the following results are true and accurate to the best ofour knowledge. BRL=below reportable limits ,*see attached Ronald J Saari Laboratory .Director Page 1 of 1 Parameters Units Test Results Reportable Limits Date Analyzed Analyst Method 'Fecal Coliform CFU/1 00 ml <10 10/100MI 08/31121 CF @ 14:30 SM 9222 D IN & Grease mg/L BRL 1.0 09118121 KB EPA 16-54-1 All samples were analyzed within the established guidelines of US EPA approved methods with all requirements met, unless otherwise noted at the end ofa given sample's analytical results. We certify that the following results are true and accurate to the best ofour knowledge. BRL=below reportable limits ,*see attached Ronald J Saari Laboratory .Director Page 1 of 1 �N 0 W 0 U LL O Z Q U >-ro LL ME 0 o N Vl R A N Z E CD= O d G 0 Co i1 c c c `ns �o ui a N Ln c N ry m o o lA O V CO CD co co 00 00 0 LO X ca LL 0 rn CO M O O co O O OO w 00 O Lol6 c O t CL L cc C cc C Z J o V U � J a� y W N (/) _ J _ 3 m w � � Co C C 4T M C C U J W LL CD E Z J W r Co xulew aldwes .G U •dwOo E .. c C) U r U C O [n C) N U. Z `- E c% O Q ✓ co Z Z Z W J W JLL -�O LL J LL W LL W CQ co C C� N y C p3 •5 • .:. _ E -2: CL co L �N U) yT Q1 c cr w a) o (n m E — _+,�0 Massachusetts Department of Environmental Protection Bureau of Resource Protection - Groundwater Discharge Program Groundwater Permit MONITORING WELL DATA REPORT C. Contaminant Analysis Information • For "0", below detection limit, less than (<) value, or not detected, enter "ND" • TNTC = too numerous to count. (Fecal results only) • NS =Not Sampled • DRY = Not enough water in well to sample. j934 1. Permit Number 2. Tax identification Number 2021 AUG MONTHLY 3. Sampling Month & Frequency Parameter/Contaminant HW -1 HW -2 HW -3 HW -4 Units Well #: 1 Well #: 2 Well #: 3 Well #: 4 Well #: 5 Well #: 6 PH 5.91 (6.22 1. 5.80 I DRY S.U. STATIC WATER LEVEL 23.07 121.26 22.49 1 DRY FEET SPECIFIC CONDUCTANCE 480 650 300 DRY UMHOS/C mwdgwp-blank.doc • rev. 09/15/15 Monitoring Well Data for Groundwater Permit • Page 1 of 1 10/1/21, 12:13 PM eDEP - MassDEP's OnlineFiling System MassDEP's Online Filing System D E P Summary & Receipt MassDEP Home I Contact I Privacy Policy Username:CASDMR Nickname: COASTAL260 Forms Signature Receipt Your submission is complete. Thank you for using eDEP's online reporting system. Select My eDEP to see a list of your transactions. Click Print Receipt to save a copy of this receipt for your records. DEP Transaction ID: 1313526 Date and Time Submitted: 10/1/2021 12:05:17 PM Other Email : DEP Transaction ID: 1313526 Date and Time Submitted: 10/1/2021 12:05:17 PM Other Email : DEP Transaction ID: 1313526 Date and Time Submitted: 10/1/2021 12:05:17 PM Other Email : DEP Transaction ID: 1313526 Date and Time Submitted: 10/1/2021 12:05:17 PM Other Email : Form Name: Groundwater Discharge Monitoring Report Forms Facility Information: Tax Identification Number: 352432096 location: 3 STATE STREET Address: BREWSTER ZIP: 02631 -/ Daily Log Sheet(2021 AUG DAILY) Form Name: Groundwater Discharge Monitoring Report Forms Facility Information: Tax Identification Number: 352432096 location: 3 STATE STREET Address: BREWSTER ZIP: 02631 */ Discharge Monitoring Report(1 - 2021 Aug Monthly) Form Name: Groundwater Discharge Monitoring Report Forms https://edep.dep.mass.gov/eDEP/Pages/Receipt.aspx 1/2 )/1/21, 12:13 PM Facility Information: Tax Identification Number: 352432096 location: 3 STATE STREET Address: BREWSTER ZIP: 02631 Vo Monitoring Well Data Report(1 - 2021 Aug Monthly) Form Name: Comments eDEP - MassDEP's OnlineFiling System MassDEP Home I Contact I Privacy Policy MassDEP's Online Filing System ver.15.21.0.0© 2019 MassDEP hftps:Hedep.dep.mass.gov/eDEP/Pages/Receipt.aspx 2/2 B 10 'R 'E 1 `y E D CBCT 05 2021 BREWS TE'HEA I 16002 West 110'h Street, Lenexa, KS 66219, Phone 913-422-0707, Fax 913-422-0808 e-mail:onsite@biomicrobics.com, www.biomicrobics.com, 800-753-FAST(3278) MASSACHUSETTS FIELD INSPECTION & SERVICE REPORT For Bio-Microbics FAST° Systems 38888 INSTALLATION AUTHORIZED SERVICE PROVIDER Installation Address: 5 Carson Way Brewster, MA 02631 Name: Wastewater Treatment Services, Inc. Owner Name: Barbara White -Holtman Mail Address: 5 Carsons Way Brewster, MA 02631 Mail Address: 44 Commercial Street Raynham, MA 02767 Phone: 802-345-2270 Fax: e-mail: Phone: (508) 880-0233 Fax: (508) 880-7232 e-mail: INSTALLATION INFORMATION Model No. Serial No. Startup Date Date of last pump out MicroFAST .5 0040845 6/23/2016 Annroval Type (x) General () Provisional () Piloting ()Remedial () General Denite Seasonal Residence () Yes (x) No EQUIPMENT YES NO MAINTENANCE PERFORMED AND COMMENTS Electrical Panel(s) Visual Alarm Operating x Audio Alarm Operating (if present) x Blower(s) Air Inlet Filter Clean x Blower Hood Vents Clear x Excessive Noise x Excessive Vibration x Treatment unit(s) Unusual Odor x Settleable Solids Test Performed x Pump out Required x Primary Settling Zone Sludge Depth 12-14" Aerobic Treatment Zone Sludge Depth Ntg" Thickness of Scum Layer 4-6" Sludge Level Distance to Outlet Depth of Ponding Within SAS Visual Observation Comments: Measurement Comments: EFFLUENT LIMIT RESULT Estimated Daily Flow 660 gpd pH (Standard Units) 6 to 9 6.3 Turbidity < 40 NTU 15-20 Dissolved Oxygen > 2 Mg/1, 7.3 Color Clear Clear Temperature 13c Odor Not Septic Earthy Effluent Solids (x) None Q Some Effluent Samples Taken: Influent: ()pH ( )BOD ()CBOD ( )TSS ()TKN ( )Nitrate ( )Nitrite () Total Nitrogen ( )Phosphorus ( )Spec. Cond. ( )Ammonia ( )Alkalinity () Oil/Grease ()VOC ( )Fecal Coliform Effluent: ()pH ( )BOD ()CBOD ( )TSS ()TKN ( )Nitrate ( )Nitrite () Total Nitrogen ( )Phosphorus ( )Spec. Cond. ( )Ammonia ( )Alkalinity ()Oil/Grease ()VOC ( )Fecal Coliform Description of any maintenance performed since previous inspection & during this inspection: Cleaned Filter, Checked Splash Recycle Notes and Comments: Pump out recommended due to heavy scum layer. Recommend pump out prior to occupancy or use next season. It is not recommended to pump the tank and leave it empty over the winter. CERTIFIED OPERATOR NAME CERTIFICATION NUMBER SERVICE DATE John Jacob Gamache 16906 4-5-21 OPERATOR SIGNATURE \J ""b COASTAL engineering co. TECHNICAL SERVICES 260 Cranberry Highway Orleans, MA 02653 508.255.6511 P 508,255.6700 F Orleans I Sandwich I Nantucket coastalengineeringcompany,com To: Brewster Town Hall Date: Board of Health Department 2198 Main St Via: Brewster, MA 02631 Subject: Cape Cod Sea Camps 3057 Main Street Brewster, MA GWDP 977-0 Plans E] Copy of Letter Specifications We are sending the following items: DECEIVE® OCT 0 5 2021 TRA FILTH 09/28/2021 Project No. C16845.02 ®1st Class Mail 0PIck up Certified Fed Ex ® Other Copies Date No. Description 1 07-08/2021 C16845.02 Daily Log Sheet (Not field-tested — Camp is Closed) 1 08/30/2021 C16845.02 Quarterly Monitor Well Discharge Report w/ laboratory test results 1 07-08/2021 C16845.02 Monthly Discharge Monitor Report (Not sampled — Camp is Closed) 1 09/28/2021 C16845.02 eDEP Electronic Receipt These are transmitted as checked below: for approval ®for your use F—las requested for reviewer comment 0 Remarks: Enclosed are the recent monthly reporting forms for the system at the above referenced location under GWDP 977-0. The laundry mat has been shut down as the camp has been permanently closed. Quarterly testing indicated none of the monitoring wells exceeded the upper containment limits for any of the tested parameters. We will continue with our scheduled testing of the monitoring wells. Please do not hesitate to contact us if you have any questions or comments. JGS/acc By: John G. Schnaible, R.S. Cc: Ed Barber, Associate Director, Facilities VIA EMAIL: edgcapecodseacamps.com VIA EMAIL: nwgarran3367gamail.com NOTE: If enclosures are not as noted, please contact us at (508) 255-6511 Orleans I Sandwich I Nantucket D:\DOC\C16800\16845.02\Transmittals\2021-10-01 Transmittal (GWDP July -August 2021).doc File No.: C16845.02 8/30/2021 Monitoring Wells Analytical Test Results Cape Cod Sea Camps 3057 Main Street Brewster, MA GWDP SE 977-0 PARAMETER UNITS CCSC-1 MW -1 MW -4 MW -5 MW -7 TOC Elevation feet 52.27 35.82 22.7 21.19 23.95 Depth To Water feet 32.54 16.30 4.75 7.19 5.59 GW Elevation feet 19.73 19.52 17.95 14.00 18.36 pH pH units 6.28 6.11 5.98 5.7 5.65 Sp. Conductance µ0cm 500 260 400 510 210 Nitrite -N mg/L <0.050 <0.050 <0.050 <0.050 <0.050 Nitrate -N mg/L 0.54 0.40 0.76 1.0 2.7 TKN-N mg/L 4.04 4.32 2.18 5.30 5.24 Total Nitrogen mg/L 4.58 4.72 2.94 6.30 7.94 Total Phosphorus mg/L 5.52 3.85 1.55 5.78 4.74 Ortho -Phosphate mg/L 0.006 0.01 <0.005 <0.005 0.054 Surfactants mg/L <2.50 <0.250 <0.250 <2.50 <2.50 VOC's ug/L ND ND ND ND ND NOTES: All tests performed at a state -certified laboratory, except pH and Sp. Conductivity, which were performed onsite with handheld test meters. ND = Not Detected, below the reporting limit of the laboratory. VOC's are tested annualy during the month of August. D:\DOC\C16800\16845.02\Discharge Monitoring\[2020 Monitor Well Reporting Forms.xls]08-30-2021 HA d_ ricAL Serial No:09072118:20 ANALYTICAL REPORT Lab Number: L2146649 Client: Coastal Engineering Company 260 Cranberry Highway Route 6A Orleans, MA 02653 ATTN: Chad Simmons Phone: (508) 255-6511 Project Name: CAPE COD SEA CAMPS Project Number: C-16845.02 Report Date: 09/07/21 The original project report/data package is held by Alpha Analytical. This report/data package is paginated and should be reproduced only in its entirety. Alpha Analytical holds no responsibility for results and/or data that are not consistent with the original. Certifications & Approvals: MA (M-MA086), NH NELAP (2064), CT (PH -0574), IL (200077), ME (MA00086), MD (348), NJ (MA935), NY (11148), NC (25700/666), PA (68-03671), RI (LA000065), TX (T104704476), VT (VT -0935), VA (460195), USDA (Permit #P330-17-00196). Eight Walkup Drive, Westborough, MA 01581-1019 508-898-9220 (Fax) 508-898-9193 800-624-9220 - www.alphalab.com Page 1 of 39 Project Name: CAPE COD SEA CAMPS Project Number: C-16845.02 09/07/21 SAMPLE RESULTS Lab ID: L2146649-01 Client ID: MW -1 Sample Location: BREWSTER, MA Sample Depth: 1 Matrix: Water Analytical Method: 128,624.1 Analytical Date: 08/31/21 21:17 Analyst: GT Serial No:09072118:20 Lab Number: L2146649 Report Date: 09/07/21 Date Collected: 08/30/21 14:30 Date Received: 08/31/21 Field Prep: Not Specified Parameter Result Qualifier Units RL MDL Dilution Factor Volatile Organics by GC/MS - Westborough Lab Methylene chloride NO ug/I 1.0 1 1,1-Dichloroethane ND ug/I 1.5 1 Chloroform ND ug/I 1.0 -- -._....._— 1 -- ....... -._.......... —...... -- Carbon tetrachloride ND ug/I 1.0 1 1,2-Dichloropropane NO ug/I 3.5 1 Dibromochloromethane ND ug/I 1.0 1 1,1,2 -Trichloroethane ND ug/I 1.5 1 2-Chloroethylvinyl ether ND ug/I 10 1 Tetrachloroethene ND ug/I 1.0 1 Chlorobenzene ND u I 3.5 1 Trichlorofluoromethane NO ug/I 5.0 1 1,2-Dichloroethane ND ug/I 1.5 1 1,1,1 -Trichloroethane ND _...._.... _ . - ug/I _ _ ... - ...-.--. 2.0 1 _... Bromodichloromethane ND ug/I 1.0 1 trans- 1,3-Dichloropropene ND ug/I 1.5 1 cis- 1,3-Dichloropropene -- ND ug/I 1.5 1 Bromoform ND ug/I 1.0 1 1,1,2,2 -Tetrachloroethane ND ug/I 1.0 1 Benzene ND ug/I 1.0 1 Toluene ND ug/I 1.0 1 Ethylbenzene - ND ug/I 1.0 ....................... . 1 Chloromethane ND ug/I 5.0 1 Bromomethane NO ug/I 5.0 1 Vinyl chloride ND ug/I 1.0 1 Chloroethane ND ug/I 2.0 1 1,1-Dichloroethene — _- ND ..... ug/I .. - 1.0 1 .... trans 1,2-Dichloroethene NO ug/I 1.5 1 cis-1,2-Dichloroethene ND ug/I 1.0 1 Al Page 7 of 39 Project Name: CAPE COD SEA CAMPS Project Number: C-16845.02 Lab ID: L2146649-01 Client ID: MW -1 Sample Location: BREWSTER, MA Sample Depth: ND Parameter 5.0 SAMPLE RESULTS Serial No:09072118:20 Lab Number: L2146649 Report Date: 09/07/21 Date Collected: 08/30/21 14:30 Date Received: 08/31/21 Field Prep: Not Specified Result Qualifier Units RL MDL Dilution Factor Volatile Organicsby GC/MS - Westborough Lab ug/I 10 1 ND Trichloroethene ND ug/I 1.0 1 1,2 -Dichlorobenzene ND ug/I 5.0 1 1,3 -Dichlorobenzene ND ug/I 5.0 1 1,4 -Dichlorobenzene ND ug/I 5.0 1 p/m-Xylene -- — ....__.._......---------- - - - -------------- -....._.._..--- - -- ND --- ug/I 2.01 o -xylene ........... .... _._. ND ug/I 1.0 1 Xylenes Total ND ug/I 1.0 1 Styrene ND ug/I 1.0 1 Acetone ND ug/I 10 1 Carbon disulfide ND ug/I 5.0 1 Surrogate ND ug/I 10 1 ND ug/I 10 1 ND ug/I 10 1 ND ug/I 10 1 ND ug/I 8.0 1 ......... ND u9 /I 10 1 ND ug/I 1.0 1 Acceptance % Recovery Qualifier Criteria Pentafluorobenzene 92 60-140 Fluorobenzene 91 60-140 4-Bromofluorobenzene 99 60-140 L&A Page 8 of 39 Project Name: CAPE COD SEA CAMPS Project Number: C-16845.02 09/07/21 SAMPLE RESULTS Lab I D: L2146649-02 Client ID: CCSC-1 Sample Location: BREWSTER, MA Sample Depth: j Matrix: Water Analytical Method: 128,624.1 Analytical Date: 08/31/21 21:54 Analyst: GT Serial No:09072118:20 Lab Number: L2146649 Report Date: 09/07/21 Date Collected: 08/30/21 14:00 Date Received: 08/31/21 Field Prep: Not Specified Parameter Result Qualifier Units RL i MDL Dilution Factor I Volatile Organics by GC/MS - Westborough Lab Methylene chloride ......... _ ND ug/I 1.0 j ...... 1,1-Dichloroethane ND ug/I 1.5 1 Chloroform ND ug/I 1.0 1 Carbon tetrachloride ND - ug/I .... . - 1.0 .. ---. 1 ........._ - - .._.. 1,2-Dichloropropane -- ND ug/I 3.5 1 --- ---......... Dibromochloromethane ND ug/I 1.0 1 1,1,2 -Trichloroethane ND ug/I 1.5 1 2-Chloroethylvinyl ether ND ug/I 10 1 Tetrachloroethene ND ug/I 1.0 1 Chlorobenzene ND ug/I 3.5 1 Trichlorofluoromethane ND ug/I 5.0 1 1,2-Dichloroethane ND ug/I 1.5 1 1,1,1 -Trichloroethane - .......... ND -- ug/I _..._ _. - 2.0 1 - ............... Bromodichloromethane ND ug/I 1.0 1 trans- l,3-Dichloropropene ND ug/I 1.5 1 - - -- cis-1,3-Dichloropropene ND ug/I 1.5 1 - ---- Bromoform ND ug/I 1.0 1 1,1 . __ Benzene ND ug/I 1.0 1 Toluene ND ug/I 1.0 1 Ethylbenzene ................ - ND ug/I 1.0 1- ............... ---- -- Chloromethane ND ug/I 5.0 1 Bromomethane ND ug/I 5.0 1 Vinyl chloride ND ug/I 1.0 1 Chloroethane ND — ug/I 2.0 — --- 1 - ----- — - ...----- - -- --- ....... _ 1,1-Dichloroethene ND ug/I 1.0 1 .. - --..... trans 1,2-Dichloroethene ND ug/I 1.5 1 cis-i,2-Dichloroethene ND ug/I 1.0 1 Page 9 of 39 Project Name: CAPE COD SEA CAMPS Project Number: C-16845.02 Lab ID: L2146649-02 Client ID: CCSC-1 Sample Location: BREWSTER, MA Sample Depth: ND Parameter 5.0 SAMPLE RESULTS Serial No:09072118:20 Lab Number: L2146649 Report Date: 09/07/21 Date Collected: 08/30/21 14:00 Date Received: 08/31/21 Field Prep: Not Specified Result Qualifier Units RL MDL Dilution Factor Volatile Organics by GC/MS - Westborough Lab 91 60-140 Fluorobenzene 92 Trichloroethene ND ug/I 1.0 1 1,2 -Dichlorobenzene ND ug/I 5.0 1 1,3 -Dichlorobenzene ND ug/I 5.0 1 1,4 -Dichlorobenzene ND ug/I 5.0 1 p/m-Xylene ND ug/I ------------ --- 2.0 - ---- 1 o-xylene ND ug/I 1.0 1 Xylenes, Total ND ug/I 1.0 1 Styrene ND ug/I 1.0 1 Acetone ND ug/I 10 1 Carbon disulfide ND ug/I 5.0 1 _..-----..........------ 2-Butanone ND ug/I 10 1 Vinyl acetate ND ug/I 10 1 4-Methyl-2-pentanone ND ug/I 10 1 2-Hexanone ND ug/I 10 1 Acrolein ND ug/I 8.0 1 Acrylonitrile ND ug/I 10 1 Dibromomethane ND ug/I1.0 1 Acceptance Surrogate % Recovery Qualifier Criteria Pentafluorobenzene 91 60-140 Fluorobenzene 92 60-140 4-Bromofluorobenzene 98 60-140 AHA Page 10 of 39 Project Name: CAPE COD SEA CAMPS Project Number: C-16845.02 09/07/21 SAMPLE RESULTS Lab ID: L2146649-03 Client ID: MW -4 Sample Location: BREWSTER, MA Sample Depth: 1 Matrix: Water Analytical Method: 128,624.1 Analytical Date: 08/31/21 22:32 Analyst: GT Serial No:09072118:20 Lab Number: L2146649 Report Date: 09/07/21 Date Collected: 08/30/21 13:30 Date Received: 08/31/21 Field Prep: Not Specified I Parameter Result Qualifier Units RL MDL Dilution Factor Volatile Organics by GC/MS - Westborough Lab Methylene chloride ND ug/I 1.0 1 1,1-Dichioroethane ND ug/I 1.5 1 Chloroform ND ug/I -- 1.0 1 — ... -...... ---.._._... - - ...---------— Carbon tetrachloride ND ug/I 1.0 1 1,2-Dichioropropane ND ug/I 3.5 1 Dibromochloromethane ND ug/I 1.0 -- 1 1,1,2 -Trichloroethane ND ug/I 1.5 1 2-Chloroethylvinyl ether ND ug/I 10 1 Tetrachloroethene ND ug/I 1.0 1 Chlorobenzene ND ug/I 3.5 1 Trichlorofluoromethane ND ug/I 5.0 1 1,2-Dichloroethane ND ug/I 1.5 1 1,1,1 -Trichloroethane ND ug/I 2.0 1 Bromodichloromethane ND ug/I 1.0 1 trans-1,3-Dichloropropene ND ug/I 1.5 - 1 ...-.. — cis-1,3-Dichloropropene ND ug/I 1.5 1 --- Bromoform ND ug/I 1.0 1 1,1,2,2 -Tetrachloroethane ND ug/I 1.0 1 ..... ..... Benzene ND ug/I 1.0 1 _.— Toluene ND ug/I 1.0 - 1 —......—.— Ethylbenzene --- ----------- ND ug/I 1.0 ...... 1 ..... .. Chloromethane ND ug/I 5.0 1 Bromomethane ND ug/I 5.0 1 Vinyl chloride ND ug/I 1.0 1 Chloroethane ND ug/I 2.0 —.... — — 1 --- ..... -- 1 -- ---- ----- ...-- -- -- .. _... ... - - trans-1,2-Dichloroethene ND ug /I 1.5 ......... -- ...... 1- ....... I - cis -1,2 Dichloroethene ND ug/I 1.0 1 V HA Page 11 of 39 Project Name: CAPE COD SEA CAMPS Project Number: C-16845.02 Lab ID: L2146649-03 Client ID: MW -4 Sample Location: BREWSTER, MA Sample Depth: Parameter SAMPLE RESULTS Serial No:09072118:20 Lab Number: L2146649 Report Date: 09/07/21 Date Collected: 08/30/21 13:30 Date Received: 08/31/21 Field Prep: Not Specified Result Qualifier Units RL MDL Dilution Factor Volatile Organics by GC/MS - Westborough Lab ug/I 10 1 Trichloroethene ND ug/I 1.0 1 1,2 -Dichlorobenzene ND ug/I 5.0 1 1,3 -Dichlorobenzene ND ug/I 5.0 1 1,4 -Dichlorobenzene ND ug/I 5.0 ...... _.. 1 p/m-Xylene ND ug/I 2.0 1 o -xylene ND ug/I 1.0 1 Xylenes, Total ND ug/I 1.0 1 Styrene ND ug/I 1.0 1 Acetone ND ug/I 10 1 Carbon disulfide ND ug/I 5.0 1 Surrogate Pentafluorobenzene Fluorobenzene 4-Bromofluorobenzene Page 12 of 39 ND ug/I 10 1 ND ug/I 10 1 ND ug/I 10 1 ND ug/I 10 1 ND ug/I 8.0 1 ND ug/I 10 1 ND ug/I 1.0 1 Acceptance % Recovery Qualifier Criteria 91 60-140 92 60-140 98 60-140 Project Name: CAPE COD SEA CAMPS Project Number: C-16845.02 09/07/21 SAMPLE RESULTS Lab ID: L2146649-04 Client ID: MW -5 Sample Location: BREWSTER, MA Sample Depth: 1 Matrix: Water Analytical Method: 128,624.1 Analytical Date: 08/31/21 23:09 Analyst: GT Serial No:09072118:20 Lab Number: L2146649 Report Date: 09/07/21 Date Collected: 08/30/21 13:00 Date Received: 08/31/21 Field Prep: Not Specified Parameter Result Qualifier Units RL MDL Dilution Factor Volatile Organics by GC/MS - Westborough Lab Methylene chloride ND ug/I 1.0 1 1,1-Dichloroethane ND ug/I 1.5 1 Chloroform ND ug/I 1.0 1 Carbon tetrachloride ND ug/I 1.0 1 1,2-Dichloropropane ND ug/I _..._ 3.5 -- 1 ........ Dibromochloromethane ND ug/I 1.0 1 1,1,2 -Trichloroethane ND ..... _..... ug/I 1.5 1 - - 2-Chloroethylvinyl ether ND ug/I 10 1 Tetrachloroethene ND ug/I 1.0 1 Chlorobenzene ND ug/I 3.5 1 Trichlorofluoromethane ND ug/I 5.0 1 1,2-Dichloroethane ND ug/I 1.5 1 1,1,1 -Trichloroethane ND ug/I 2.0 1 Bromodichloromethane ND ug/I 1.0 1 trans-1,3-Dichloropropene ND ug/I 1.5 1 cis- 1,3-Dichloropropene ND ug/I 1.5 1 Bromoform ND ug/I 1.0 1 1,1,2,2 -Tetrachloroethane ND ug/I 1.0 1 Benzene ND ug/I 1.0 1 Toluene ND ug/I 1.0 1 Ethylbenzene ND ug/I 1.0 1 Chloromethane ND ug/I 5.0 -- 1 Bromomethane ND ug/I 5.0 1 Vinyl chloride ND ug/I 1.0 1 Chloroethane ND ...... -- ug/I — - — 2.0 -- 1 ------ ------ -- .....— ... ..... ....... —._..._—_ _-----........ 1,1-Dichloroethene ----- ND ug/I 1.0 1 trans 1 2 Dichloroethene ND ug/I 1.5 1 cis -1 2 Dichloroethene ND ug/I 1.0 1 AHA ,. .:ars;. �,: Page 13 of 39 Project Name: CAPE COD SEA CAMPS Project Number: C-16845.02 Lab ID: L2146649-04 Client ID: MW -5 Sample Location: BREWSTER, MA Sample Depth: Not Specified Parameter 5.0 SAMPLE RESULTS Serial No:09072118:20 Lab Number: L2146649 Report Date: 09/07/21 Date Collected: 08/30/21 13:00 Date Received: 08/31/21 Field Prep: Not Specified Result Qualifier Units RL MDL Dilution Factor Volatile Organics by GC/MS - Westborough Lab ND Vinyl acetate ND 4-Methyl-2-pentanone Trichloroethene ND ug/I 1.0 1 ........ 1,2 -Dichlorobenzene ND ug/I 5.0 1 1,3 -Dichlorobenzene ND ug/I 5.0 1 1,4 -Dichlorobenzene ND ug/I 5.0 1 p/m-Xylene ND ug/I 2.0 1 o -xylene - - ..... ND ug/I 1.0 1 Xylenes, Total ND ug/I 1.0 1 Styrene ND ug/I 1.0 1 Acetone ND ug/I 10 1 Carbon disulfide ND ug/I 5.0 1 2-Butanone ND Vinyl acetate ND 4-Methyl-2-pentanone ND 2-Hexanone ND Acrolein ND Acrylonitrile ND Dibromomethane ND Surrogate ug/I 10 1 ug/I 10 1 ug/l 10 1 ug/I 10 1 ug/I 8.0 1 ug/I 10 1 ug/I 1.0 1 Acceptance % Recovery Qualifier Criteria Pentafluorobenzene 91 60-140 Fluorobenzene 92 60-140 4-Bromofluorobenzene 99 60-140 Page 14 of 39 Project Name: CAPE COD SEA CAMPS Project Number: C-16845.02 SAMPLE RESULTS Lab ID: L2146649-05 Client ID: MW -7 Sample Location: BREWSTER, MA Sample Depth: ug/I Matrix: Water Analytical Method: 128,624.1 Analytical Date: 08/31/21 23:47 Analyst: GT Parameter Result Qualifier Units Serial No:09072118:20 Lab Number: L2146649 Report Date: 09/07/21 Date Collected: 08/30/21 12:45 Date Received: 08/31/21 Field Prep: Not Specified RL MDL Dilution Factor Volatile Organics by GC/MS - Westborough Lab Methylene chloride ND ug/I 1.0 1 1,1-Dichloroethane ND ug/I 1.5 1 Chloroform ND ug/I 1.0 1 Carbon tetrachloride ND ug/I 1.0 1 1,2-Dichloropropane -- ND ug/I 3.5 1 -- - Dibromochloromethane ND ug/I 1.0 1 1,1,2 -Trichloroethane ND ug/I 1.5 1 2-Chloroethylvinyl ether ND - — - ug/I -- --------------- 10 1 _...._... Tetrachloroethene ND ug/I 1.0 1 Chlorobenzene ND ug/I 3.5 1 Trichlorofluoromethane ND ug/I 5.0 1 1,2-Dichloroethane ND ug/I 1.5 1 1,1,1 -Trichloroethane -.... ND .... _. ug/I 2.0 1 _...... Bromodichloromethane ND _— ..... _...... ug/I 1.0 1 — --- trans-1,3-Dichloropropene ND ug/I 1.5 1 cis-1,3-Dichloropropene ND ug/I 1.5 i - --- Bromoform ND ug/I 1.0 1 1,1,2,2 -Tetrachloroethane ND ug/I 1.0 1 Benzene ND ug/I 1.0 1 Toluene ND ug/I 1.0 1 Ethylbenzene ND ug/I 1.0 1 Chloromethane ND ug/I 5.0 1 Bromomethane ND ug/I 5.0 1 Vinyl chloride ND ug/I 1.0 1 Chloroethane ND ug/I 2.0 1 1, 1 -Dichloroethene ......... - ND ug/I 1.0 1 -- trans 1 2 Dichloroethene ND - ug/I - -- 1.5 1 .. cis-1,2-Dichloroethene ND ug/I 1.0 1 rr Page 15 of 39 Project Name: CAPE COD SEA CAMPS Project Number: C-16845.02 Lab ID: 'Client ID: Sample Location Sample Depth: Parameter L2146649-05 MW -7 BREWSTER, MA SAMPLE RESULTS Result Qualifier Units Serial No:09072118:20 Lab Number: L2146649 Report Date: 09/07/21 Date Collected: 08/30/21 12:45 Date Received: 08/31/21 Field Prep: Not Specified RL MDL Dilution Factor Volatile Organics by GC/MS - Westborough Lab 10 1 ug/I 10 Trichloroethene ND ug/I 1.0 1 ....... 1,2 -Dichlorobenzene ND ug/I 5.0 1 1,3 -Dichlorobenzene ND ug/I 5.0 1 1,4 -Dichlorobenzene ND ug/I 5.0 .... 1 p/m-Xylene -- -- ------ ND ug/I - - 2.0 1 -- -- - .. .--- .. o -xylene ND ug/I 1.0 1 Xylenes, Total ND ug/I 1.0 1 Styrene ND ug/I 1.0 1 Acetone ND ug/I 10 1 Carbon disulfide ND ug/I 5.0 1 2-Butanone Vinyl acetate 4-Methyl-2-pentanone 2-Hexanone Acrolein Acrylonitrile Dibromomethane Surrogate ug/I 10 1 ug/I 10 1 ug/I 10 1 ug/I 10 1 ug/l 8.0 1 ug/I 10 1 ug/I 1.0 1 Acceptance % Recovery Qualifier Criteria Pentafluorobenzene 90 60-140 Fluorobenzene 89 60-140 4-Bromofluorobenzene 100 60-140 Page 16 of 39 Project Name: CAPE COD SEA CAMPS Project Number: C-16845.02 Method Blank Analysis Batch Quality Control Analytical Method: 128,624.1 Analytical Date: 08/31/21 15:04 Analyst: MKS Serial No:09072118:20 Lab Number: L2146649 Report Date: 09/07/21 Parameter Result Qualifier units RL MDL Volatile Organics by GC/MS -Westborough Lab for sample(s): 01-05 Batch: WG1541708-4 Methylene chloride ND ug/I 1.0 -- ——.._.......... .............. _...— 1,1-Dichloroethane ND ug/I 1.5 Chloroform ND ug/I 1.0 Carbon tetrachloride ND ug/I 1.0 1,2 Dichloropropane ND ug/I 3.5 Dibromochloromethane ND ug/I 1.0 ......... 1,1,2 Trichloroethane ND ug/I 1.5 2-Chloroethylvinyl ether ND ug/I 10 Tetrachloroethene ND ug/I 1.0 Chlorobenzene ND ug/I 3.5 Trichlorofluoromethane ND ug/I 5.0 -__ ......... 1,2-Dichloroethane ND ug/I 1.5 ..... 1,1,1 -Trichloroethane ND ug/I 2.0 Bromodichloromethane ND ug/I 1.0 trans-1,3-Dichloropropene ND ug/I 1.5 cis-1,3-Dichloropropene ND ug/I 1.5 Bromoform ND ug/I 1.0 1,1,2,2 -Tetrachloroethane N D ug/I 1.0 Benzene ND ug/I 1.0 Toluene ND ug/I 1.0 Ethylbenzene .. ND ug/I 1.0 Chloromethane ND ............ ug/I 5.0 Bromomethane —.....---------- ND — -- ug/I --- .._...--- .........__.—.— ....... _. 5.0 Vinyl chloride ND ug/I 1.0 ------- ---- .. — ---- ---- -- — Chloroethane — ....._... -------------------------------------------------- ND ug/I 2.0 1,1-Dichloroethene ND ug/I 1.0 trans-1,2-Dichloroethene ND ug/I 1.5 - cis-1,2-Dichloroethene ND ug/I .. __ 1.0 — - - - .... - . Trichloroethene -- ND ug/I 1.0 Page 17 of 39 Project Name: Project Number: Analytical Method Analytical Date: Analyst: CAPE COD SEA CAMPS C-16845.02 128,624.1 08/31/21 15:04 MKS Method Blank Analysis Batch Quality Control Serial No:09072118:20 Lab Number: L2146649 Report Date: 09/07/21 Parameter Result Qualifier units RL MDL Volatile Organics by GC/MS -Westborough Lab for sample(s): 01-05 Batch: WG1541708-4' 1,2 -Dichlorobenzene ND ug/I 5.0 — 1,3 -Dichlorobenzene ---- ............ ND ug/I 5.0 1,4 -Dichlorobenzene ND ug/I 5.0 p/m-Xylene ND ug/I 2.0 o -xylene ND ug/I 1.0 Xylenes, Total ND ug/I 1.0 Styrene ND ug/I 1.0 Acetone ND ug/I 10 Carbon disulfide ND ug/I 5.0 2-Butanone ND ug/I 10 Vinyl acetate ND ug/I 10 4-Methyl-2-pentanone ND ug/I 10 2-Hexanone ND ug/I 10 Acrolein ND ug/I -- 8.0 Acrylonitrile ND ug/I 10 Dibromomethane ND ug/I 1.0 Acceptance Surrogate %Recovery Qualifier Criteria Pentafluorobenzene 91 60-140 Fluorobenzene 90 60-140 4-Bromofluorobenzene 92 60-140 Page 18 of 39 Project Name: CAPE COD SEA CAMPS Project Number: C-16845.02 Lab ID: L2146649-01 Client ID: MW -1 Sample Location: BREWSTER, MA Sample Depth: Matrix: Water Parameter Result Qualifier Units General Uriemistry - Westborough Lai) SAMPLE RESULTS RL Serial No:09072118:20 Lab Number: L2146649 Report Date: 09/07/21 Date Collected: 08/30/21 14:30 Date Received: 08/31/21 Field Prep: Not Specified Dilution Date Date Analytical MDL Factor Prepared Analyzed Method Analyst Nitrogen, Nitrite ND mg/I 0.050 1 09/01/21 05:01 44,353.2 MR Nitrogen, Nitrate 0.40 mg/I 0.10 1 - 09/01/21 05:01 44,353.2 MR Nitrogen, Total Kjeldahl 4.32 mg/I 3.00 10 09/02/21 12:30 09/03/21 18:29 121,4500NH3-H AT Phosphorus, Total 3.85 mg/I 0.100 10 09/01/21 08:55 09/01/21 13:11 121,4500P -E SD Phosphorus, Orthophosphate 0.010 mg/I 0.005 1 - 08/31/21 22:46 121,4500P -E AS Surfactants, MBAS ND mg/I 0.250 -- 5 09/01/21 01:40 09/01/21 05:34 121,5540C KA Page 23 of 39 Project Name: CAPE COD SEA CAMPS Project Number: C-16845.02 Lab ID: L2146649-02 Client ID: CCSC-1 Sample Location: BREWSTER, MA Sample Depth: Matrix: Water Parameter Result Qualifier Units SAMPLE RESULTS RL Serial No:09072118:20 Lab Number: L2146649 Report Date: 09/07/21 Date Collected: 08/30/21 14:00 Date Received: 08/31/21 Field Prep: Not Specified Dilution Date Date Analytical MDL Factor Prepared Analyzed Method Analyst General Chemistry - Westborough Lab Nitrogen, Nitrite ND mg/I 0.050 1 09/01/21 05:03 44,353.2 MR Nitrogen, Nitrate 0.54 mg/I 0.10 1 09/01/21 05:03 44,353.2 MR Nitrogen, Total Kjeldahl 4.04 mg/I 3.00 10 09/02/21 12:30 09/03/21 18:30 121,4500NH3-H AT Phosphorus, Total 5.52 mg/I 0.100 10 09/01/2108:55 09/01/2113:12 121,4500P -E SD Phosphorus Orthophosphate 0.006 mg/I 0.005 1 08/31/21 22:46 121,4500P -E AS Surfactants, MBAS ND mg/I 2.50 50 09/01/21 01:40 09/01/21 05:34 121,5540C KA Page 24 of 39 Project Name: CAPE COD SEA CAMPS Project Number: C-16845.02 SAMPLE RESULTS Lab ID: L2146649-03 Client ID: MW -4 Sample Location: BREWSTER, MA Sample Depth: Matrix: Water Serial No:09072118:20 Lab Number: L2146649 Report Date: 09/07/21 Date Collected: 08/30/21 13:30 Date Received: 08/31/21 Field Prep: Not Specified Page 25 of 39 Dilution Date Date Analytical Parameter Result Qualifier Units RL MDL Factor Prepared Analyzed Method Analyst General Chemistry - Westborough Lab Nitrogen, Nitrite ND mg/I 0.050 1 09/01/21 05:04 44,353.2 MR Nitrogen, Nitrate 0.76 mg/I 0.10 1 - 09/01/21 05:04 44,353.2 MR Nitrogen, Total Kjeldahl 2.18 mg/I 1.50 5 09/02/21 12:30 09/03/21 18:31 121,4500NH3-H AT Phosphorus, Total 1.55 mg/I 0.100 10 09/01/21 08:55 09/01/21 13:13 121,4500P -E _ SD Phosphorus, Orthophosphate ND mg/I 0.005 1 - 08/31/21 22:46 121,4500P -E AS - -- Surfactants, MBAS ND mg/I 0.250 --...... -- 5 _........ .----....__ 09/01/21 01:40 09/01/21 05:35 121,5540C KA Page 25 of 39 Project Name: CAPE COD SEA CAMPS Project Number: C-16845.02 Lab ID: L2146649-04 Client ID: MW -5 Sample Location: BREWSTER, MA l Sample Depth: Matrix: Water Parameter Result Qualifier Units SAMPLE RESULTS RL Serial No:09072118:20 Lab Number: L2146649 Report Date: 09/07/21 Date Collected: 08/30/21 13:00 Date Received: 08/31/21 Field Prep: Not Specified Dilution Date Date Analytical MDL Factor Prepared Analyzed Method Analyst General Chemistry - Westborough Lab Nitrogen, Nitrite ND mg/I 0.050 1 09/01/21 05:05 44,353.2 MR . . -..... _.._...... Nitrogen, Nitrate 1.0 mg/I 0.10 1 09/01/21 05:05 44,353.2 MR Nitrogen, Total Kjeldahl 5.30 mg/I 1.50 5 09/02/21 12:30 09/03/21 18:32 121,4500NH3-H AT Phosphorus, Total 5.78 mg/I 0.100 10 09/01/21 08:55 09/01/21 13:14 121,4500P -E SD Phosphorus, Orthophosphate ND mg/I 0.005 1 08/31/21 22:47 121,4500P -E AS Surfactants, MBAS ND mg/I 2.50 50 09/01/21 01:40 09/01/21 05:37 121,5540C KA Page 26 of 39 • Project Name: CAPE COD SEA CAMPS Project Number: C-16845.02 Lab ID: L2146649-05 Client ID: MW -7 Sample Location: BREWSTER, MA Sample Depth: Matrix: Water Parameter Result Qualifier Units SAMPLE RESULTS RL Serial No:09072118:20 Lab Number: L2146649 Report Date: 09/07/21 Date Collected: 08/30/21 12:45 Date Received: 08/31/21 Field Prep: Not Specified Dilution Date Date Analytical MDL Factor Prepared Analyzed Method Analyst General Chemistry - Westborough Lab Nitrogen, Nitrite ND mg/I 0.050 1 09/01/21 05:06 44,353.2 MR Nitrogen, Nitrate 2.7 mg/I 0.10 1 09/01/21 05:06 44,353.2 MR Nitrogen, Total Kjeldahl 5.24 mg/I 1.50 5 09/02/21 12:30 09/03/21 18:39 121,4500NH3-H AT Phosphorus, Total 4.74 mg/I 0.100 10 09/01/21 08:55 09/01/21 13:15 121,4500P -E SD Phosphorus, Orthophosphate 0.054 mg/I 0.005 1 - 08/31/21 22:47 121,4500P -E AS — --------------... Surfactants, MBAS ND - — mg/I ------_--- 2.50 50 09/01/21 01:40 09/01/21 05:38 121,5540C KA Page 27 of 39 0 N 66 T T N t- o rn 0 0 Z I U) Massachusetts Department of Environmental Protection eDEP Transaction Copy Here is the file you requested for your records. rDEPART V E D To retain a copy of this file you must save and/or print.OCT 2021 HEALTH MENT Username: EBELAIR Transaction ID: 1306750 Document: Groundwater Discharge Monitoring Report Forms Size of File: 714.07K Status of Transaction: Submitted Date and Time Created: 9/20/2021:9:20:43 AM Note: This file only includes forms that were part of your transaction as of the date and time indicated above. If you need a more current copy of your transaction, return to eDEP and select to "Download a Copy" from the Current Submittals page. vuicau vi 1\GJVUIVG i iv�c,uvii - vivwiuvvacuro�.iaiyc i IVVI Cal i i. r c1 nut ivunwci Groundwater Permit 2. Tax identification Number MONITORING WELL DATA REPORT 2021 AUG MONTHLY 3. Sampling Month & Frequency A. Facility Information Important:when filling out forms on 1. Facility name, address: the computer, use JIBREWSTER MANOR only the tab key to a. Name move your cursor - 873 HARWICH ROAD do not use the return key. b. Street Address BREWSTER MA 102631 C. City d. State e. Zip Code 2. Contact information: Mm DAVID FELDMAN a. Name of Facility Contact Person 7817079527 dfeldman@wingatehealthcare.com b. Telephone Number c. e-mail address 3. Sampling information: 8/20/2021 IRI ANALYTICAL a. Date Sampled (mm/dd/yyyy) b. Laboratory Name DOUG MURPHY c. Analysis Performed By (Name) B. Form Selection 1. Please select Form Type and Sampling Month & Frequency Monitoring Well Data Report - 2021 Aug Monthly All forms for submittal have been completed. 2. This is the last selection. 3. Delete the selected form. gdpols 2015-09-15.doc • rev. 09/15/15 Groundwater Permit Daily Log Sheet • Page 1 of 1 VUI GQU VI 1%GIzov 11 Vv 1 IVtGvtIVII — VI VUI IUVVQLVI VIJ VI IQI t`. 1 IVtJ.ICal 11 1, F V1111lt IVUIIIVQI R. Groundwater Permit L MONITORING WELL DATA REPORT 2• Tx identification Number 'i, 2021 AUG MONTHLY 3. Sampling Month & Frequency C. Contaminant Analysis Information • For "0", below detection limit, less than (<) value, or not detected, enter "ND" < • TNTC = too numerous to count. (Fecal results only) • NS =Not Sampled • DRY = Not enough water in well to sample. Parameter/Contaminant MW1 MW2 MW3 MW4 Units Well #: 1 Well #: 2 Well #: 3 Well #: 4 Well #: 5 Well #: 6 PH 5.7 115.6 15.9 5.9 S.U. STATIC WATER LEVEL 59.73 158.98 1159.67 126.85 FEET SPECIFIC CONDUCTANCE 442 403 211 135 UMHOS/C mwdgwp-blank.doc • rev. 09/15/15 Monitoring Well Data for Groundwater Permit • Page 1 of 1 vw 'au vi i*cJwui'.c ivcv.uvii - vivwu vvaci VIJlrllalyG i ivyiani. roinnt ivuniuci Groundwater Permit 2. Tax identification Number L DISCHARGE MONITORING REPORT L 2021 AUG MONTHLY Y 3. Sampling Month & Frequency A. Facility Information Important:When filling out forms on 1. Facility name, address: the computer, use JBIREWSTER MANOR only the tab key to a. Name move your cursor - 873 HARWICH ROAD do not use the return key. b. Street Address BREWSTER IMA 02631 C. City d. State e. Zip Code 2. Contact information: rm DAVID FELDMAN a. Name of Facility Contact Person 7817079527 dfeldman@wingatehealthcare.com b. Telephone Number c. e-mail address 3. Sampling information: 8/31/2021 JR1 ANALYTICAL a. Date Sampled (mm/dd/yyyy) b. Laboratory Name NICOLE SKYLESON c. Analysis Performed By (Name) B. Form Selection 1. Please select Form Type and Sampling Month & Frequency Discharge Monitoring Report - 2021 Aug Monthly -31 )- All forms for submittal have been completed. 2. 1- This is the last selection. 3.- Delete the selected form. gdpols 2015-09-15.doc • rev. 09/15/15 Groundwater Permit Daily Log Sheet • Page 1 of 1 Uul GQu VI I\GJVu1 Vu I IVIGVUVII - VI Vul Iu VVQLGI 1. loI lIQ1 UV I IVI,.l Q111 1. r V1 1111t IYu1111.161 Groundwater Permit DISCHARGE MONITORING REPORT 2. Tax identification Number L 12021 AUG MONTHLY L 3. Sampling Month & Frequency D. Contaminant Analysis Information • For "0", below detection limit, less than (<) value, or not detected, enter "ND" • TNTC = too numerous to count. (Fecal results only) • NS =Not Sampled 1. Parameter/Contaminant 2. Influent 3. Effluent 4. Effluent Method Units Detection limit BOD 183 NS NS MG/L TSS 480 NS I NS MG/L TOTAL SOLIDS 690 MG/L AMMONIA -N 17.8 MG/L NITRATE -N INS I N S MG/L TOTAL NITROGEN(NO3+NO2+TKN) INS NS MG/L OIL & GREASE NS NS MG/L infeffrp-blank.doc • rev. 09/15/15 Groundwater Permit Discharge Monitoring Report • Page 1 of 1 accordance with a system designed to assure that qualified personnel properly gather and evaluate the information submitted. Based on my inquiry of the person or persons who manage the system, or those persons directly responsible for gathering the MMA information, the information submitted is, to the best of my knowledge and belief, true, accurate and complete. I am aware that the are significant penalties for submitting false information, including the possibility of fine and imprisonment for knowing violations." ELIZABETH BELAIR 9/17/2021 Any person signing a. Signature b. Date (mm/dd/yyyy) a document under 314 CMR 5.14(1) or (2) shall make the Reporting Package Comments following PLANT DID NOT DISCHARGE FOR AUGUST 2021. 39,900 GALLONS WERE PUMPED OFFSITE certification WHILE METAL REHAB. WAS BEING PERFORMED IN THE PLANT. If you are filing electronic -ally and want to attach additional comments, select the check box. gdpols 2015-09-15.doc • rev. 09/15/15 Groundwater Permit • Page 1 of 1 UUIGg4 VI I\GJVVI UG I IVIGVLIVII- VI VVI IVVVCILGI VIJ6r11gIl,.G I I VV I CAR II I. rG11111I 11R.1111VGI 1,L Groundwater Permit /y 2. Tax identification Number Facility Information Important:When gREWSTER MANOR filling out forms on a. Name the computer, use only the tab key to 873 HARWICH ROAD move your cursor - b. Street Address do not use the IBREWSTER MA 02631 return key. C. City d. State e. Zip Code Certification "I certify under penalty of law that this document and all attachments were prepared under my direction or supervision in accordance with a system designed to assure that qualified personnel properly gather and evaluate the information submitted. Based on my inquiry of the person or persons who manage the system, or those persons directly responsible for gathering the MMA information, the information submitted is, to the best of my knowledge and belief, true, accurate and complete. I am aware that the are significant penalties for submitting false information, including the possibility of fine and imprisonment for knowing violations." ELIZABETH BELAIR 9/17/2021 Any person signing a. Signature b. Date (mm/dd/yyyy) a document under 314 CMR 5.14(1) or (2) shall make the Reporting Package Comments following PLANT DID NOT DISCHARGE FOR AUGUST 2021. 39,900 GALLONS WERE PUMPED OFFSITE certification WHILE METAL REHAB. WAS BEING PERFORMED IN THE PLANT. If you are filing electronic -ally and want to attach additional comments, select the check box. gdpols 2015-09-15.doc • rev. 09/15/15 Groundwater Permit • Page 1 of 1 OXS.7 SITZ Z Mot to* Seale � , 1. NO HERBICIDES TO BE USED ON SUBJECT LLAT. 2. UMTS OF CONSTRUCTION ANDIOR GRADING TO BE AS SC14tJfJLHC1tr5E gyp. SHOWN ON PLAN AND SHALL BE VISIBLY MARKED, PRIOR ri TT TO, AND DORING CONSTRUCTION. 3. HAYBALES OR FABRIC SILTFENCE TO BE SECURELY STAKED IN 0� PLACE PRIOR TO CONSTRUCTION AND SHALL REMAIN IN -- PLACE UNTIL DISTURBED AREAS HAVE BEEN REVEGETATED. CD EDGE OF WETLAND 71 4. DISTURBED AREAS SHALL BE STABILIZED AND REVEGETATED AS SOON AS PRACTICABLE UPON COMPLETION OF GRADING. 5. ALL EXCESS EXCAVATED MATERIAL SHALL BE STOCKPILED TOP OF BANK TO THE EAST OF THE EXISTING BUILDING AND SHALL BE q� -'�� \ t REMOVED FROM THE SITE UPON COMPLETION OF CONSTRUCTION. "po EDGE OF WETLAND d 6. ANY ADDITIONAL WORK BEYOND THE SCOPE OF THAT WHICH i \ IS SHOWN HEREON, AND WHICH IS WITHIN 100 OF THE I WETLAND, WILL REQUIRE CONSERVATION COMMISSION EDGE OF POND —� > _ APPROVAL. �4ssr s a_p .24 'Ra7lCel 59 ICP 326-25 14 50' FROM TOP OF SANK/EDGE OF WETLAND ABANDONED,xTING SPOOLS TO BE SPUMPED DR AND i FILLED WITH CLEAN SAND. t t SCIZ 01ho se IiLj ! '�' ,' 1.00' FROM TOFF OF BANK/EDGE OF WETLAND j Pond � 1 I 1 t / i ✓ f i �- /' i / � 5'���O �r�.�� � TOP OF C. 3. F ND r, tI 11 I / / // // / i r®��, %�� Water e1ev. = 28_.3' (5/00) 1i I I I f� :�/ /� ii �� �� / �. ELEV.= 60.00 V J I I > f' .-.• 'BREAKOUT" 1 (ASSUMED DATUM) t I 1,50 S-T.zt CONTOUR X''" .01 F��TUE Cj PO Co �-'" j RESERVE\C,� 1 r` / � r 58.57. r , LA NE Test doze location —��— Existing contour 0 o Q Septic tank ,p chamber y S17 7Z — Distribution boy --j------------- { 4f7 , X IfA? ' X L— e Absorption C$.L�C} bel ® _ Prep i I- .�t4 / SJ / J � 10 Z7 ff L--------___-_ --- --- system4 h Concrete bound — meter seruice Ryder ileo , Inc.. I? E P L 65' t� „ 3Cid is Hill i - � s So. Orleans, , ., 02662 Scale: f--30' 'Tel. (6708) :26-6 – 831A;? Dra wn 6 y CJR Via.. x 50,9 .240-.2306 Date JUAIZ 8, 2000 6 S eet oL'7'.tf o. 7,9 49 a oQdew is" 1. S I L BE: YER:� 50 0-5 H -P. OR APPROVED 4: PUMP SHALL BE EQUIPPED WITH AN AUDIO AND VISUAL ALARM in accordance t, "Commonwealth , ecalt1 o � �, ate zs sties at t - -- . I T T IN TALL D IN A BUILDING a 0 PROVIDE EQUATE WARNING IN CASs=. o aav� a� � al tectioa�, 31x7 C' .R � t�'e�. ; the State 1'�titt��' a;'ort€�, LOCAL° AND SHALL BE LE OF PASSING A LEAS 1_25 S E I 1 T F PUMP FAILURE. R SHALL BE PO "RED BY A CIRCUIT �'xte 5:-_ stt.� ia-e s �- t' Sitan�g COt to :l• ctzo SOLD AT A DISCHARGE TE OF 575 GPM � 21_ I�Hi O iI a_U E aazr zoa o {az-ste Se e Twat alis sal SystemsSEP TE FROM THE PUMP POSER. and tta .7'o of tar Regulations 5�2. ,SUMP SkALL BE INSTALLED IN STRICT CONFORMANCE WITH .t MANUFACTURER'S SPECIFICATIONS. _ ,�. �o tr's or water .�.aes tzar to exist aarat}aan e'a�a� a?i: of t5_ CHECK VALVE, AUTOMATIC CONTROL Ahff� CONTROL BOX S�-aALL BE proposed leaching stem All wells known to ez st within 150 , `. of the AS SPECIFIED BY PUMP NUFACTURER. st are shown. .5. PUMP CONIPOLS SHALL BE MOISTURE PROOF AND OPERATE IN � c �� THE FOLLOJI�'G SEOUEi�iCE: 6_ CONTRACTOR SHALL PRESSURE TEST FORCE IslA1N TO ASSURE or to back ling com eted s ste , ti t Fng er �ata� t Board o f � WATERT GH`TNESS. taltk ,3�or -iction. vi engineer Zf-kour (' im) notice ,dor i s ctio� A) PUMP OFF 0. Contractor shall be _responsible for location o all underu B) PUMP ON 7. IT IS RECOMMENDED ENDED THAT A SLIDE RAIL SYSTEM BE INSTALLED tilities r to excavation. C) ALARM OSI TO FACILITATE REMOVAL OF PUMP FOR INSPECTION ANIS 4ny c s to this plan must be appmved by the Board of Heath, €MAINTENANCE. 5 .Lot zs served by Town water. T�J .t T.d� TCIT a 'ot to scale Tank to be instaded on to level, THRUST BLOCKING SHALL BE stable base (min -6- sto base) PROVIDED AT ALL BENDS TO PREVENT DISRUPTION OF PROPER FUNCTIONING fNCTIONING OF LINE. Trp a7 slab 20 � DIA_ COVER 7 .Zf�" 1Jira. cover .2aJ"" I>ia � TO WITHIN 6'> OF to 'ttain 6 in.. 1I �e rs FINISH GRADE 1e21 = 63 06 tB - � o f ��zzsiz €ae / % � � ':h Ina_ 1Fl" irz 113' 0 run 6.41.0D ;� Ie' NEMA 4X to be 19 rf _ JUNCTiON BOX BLEEDER 2 ^ DIA_ FORCE CAIN m ,�� o ` � � ` zo ti CHECK S0 PSC E en �'d'JTS' 'I1v`6 15€?® I zJ ZAL VE �� Inv. I GATE = 15 �t 64.42 CapacityE s;3 76 r UAL VE 6� 25 ` c �1 ��eozTa . `E EE or scizeri.40 a � O �# � *PROVIDE INLET TEE t `° =------------------------ P. l' ( eT fFgAt of c EZ_ AP OQED PUMP O EXTENDING TO I- -66 " 53 6 S EC aAL. 27' ABOVE OUTLET t E�'T_ Tat zf PUMP OFF 'Vo gar6agge s 8" (SUMP) 674.00 d with this esti oa < _ .: tt lev = 4R 15 *CONTRACTOR SHALL tube � �` VERIF' LOCATION OF 411 tees shaZZ be cast irvn— Afaintain a maxzmum of 36"cozier over ALL EXISTING WASTE or sc a- �fi P V G P-Lpe or 1000 -GAL. SEPTIC TANK SHALL BE all s3estem co s. All components PIPES PRIOR RQ cast- in cone te, UT6LiZED• PNST4LL ON A LEVEL. s ll co7a,o fo s i�caztzo coatai a - t INSTALLING TAN�CS. .a ,�. .��-�,.-,�,..��.�.'�t _-. E ...,aSE_ � G .sTt?a� B,�SE, - _ _ �rr JO TT 1-1 J 4 'T BACKS LL TIGHTLY i iC3 PREVENT SEEPAGE :F SURFACE WATER. (6700_ C,4L. „�C PJB .QST° UVITS, OR .L) mot to scale F? a� e 3XW°'-1 I/. ' utile e 6780 wase sto �t p 1 7 Mini zea of r1) zi to s inspection co r stonerTyp , plT�r1 T % regui al' r unit IV Umber o be€rooms 3 T' L.J /o Win• lud -'sti tett dazly eff nt . 6 1 top s iota stair' I'otral leaching a as as sett s -------- ----------- ---------�-------------- k Sidewall: cl'L� z = 236' FF. o P 3 P L pPk � p� E E , a � _ �° g sn Zeaacizing Capacity as sed 6�` �t$zfe T T ' d . vent loading to - li_ 56 6.P..t.�/5'F) s°. a a m ars E c --------------------------- -------------------J tlis EII D - EE II S ' ewall- 0 56 a- 236 = t32 2 a iE °� Bottom = 6.c? 00 ?. 66 ? J 67. Bottom- 0.56 z 564 = 715.8 66.5 A4' aaiaa . L MI L T 7f �4 a✓ _ r3-6' S.rO. s) (,4r UVfT ' F13' OF -TOVE Z .- , ){'3 6' SJ0_FSJ . 6677 LQ �'L"C'1"L' 6' s 0�ta' _ Sit loch 7 LOAMY ' Z" ' .IDTH _ 12' ZY = 57.3 , LOAMY SA ND I 6,Z 6 SA LSSJ V✓ Z,4TJ TSrF_T_FV , NO C'2 LOAM 60.4 60. z FINE MEDIUM / ULIJ )1 1 , I I ��s.; ND C2 TO FIDE , 7 573 Rya'sr so ; Inc., , J_ Z ? .P 11 rnr SILT (. o water encountered) Cli s3 dd a -mill J�i'c. Date o lam ` X1112000 � ��� SAND C aT1S T h "INE So. rleoz 3 ` 56 ` - .5, .r. , ��� �' �S Gid. -C C'� LOAMY � ;T,.� .I�.I'r . - 1�.�-.al IBJ.. LOAM Tel 6708 255-8312 Drawn by CJR SAND. 53.0 - ` .J .` -.' T.' .PTT T .. °. Ia 2 — X306 tai a , �'ar 0 Job 9. O GENERAL TES: S1 L TEST LOGS: TEST HOLE 1: EL=49.3± A.) NEITHER DRIVEWAYS NOR PARKING AREAS ARE ALLOWED OVER SEPTIC SYSTEM UNLESS H-20 COMPONENTS ARE USED. B.) THE DESIGNER WILL NOT BE RESPONSIBLE FOR THE SYSTEM AS DESIGNED UN- LESS CONSTRUCTED AS SHOWN. ANY CHANGES SHALL BE APPROVED IN WRITING. C.) CONTRACTOR SHALL BE RESPONSIBLE FOR VERIFYING THE LOCATION OF ALL UNDERGROUND AND OVERHEAD UTILITIES PRIOR TO COMMENCEMENT OF WORK. DEPTH FROM SURFACE (INCHES) SOIL HORIZON SOIL TEXTURE (USDA) SOIL COLOR (MUNSELL) SOIL MOTTLING OTHER 0-18 A FINE LOAMY SAND 10YR 3/2 NONE 18-36 B FINE LOAMY SAND 10YR 5/8 NONE 36-58 C1 LOAMY FINE TO MED SAND 10YR 5/8 NONE FIRM 58-68 C2 SILT LOAM 10YR 6 1 NONE FIRM 68-127 C3 LOAMY MED. TO CRS. SAND 10YR 4/3 NONE 15% GRAVEL- 5% COBBLES C STmuk,TI TES° TEST HOLE 2: EL=49.4± 1.) ALL CONSTRUCTION SHALL CONFORM TO THE STATE ENVIRONMENTAL CODE, TITLE 5, AND THE REQUIREMENTS OF THE LOCAL BOARD OF HEALTH. 2.) SEPTICTANK(S), GREASE TRAP(S), DOSING CHAMBER(S) AND DISTRIBUTION BOX(ES) SHALL BE SET ON A LEVEL STABLE BASE WHICH HAS BEEN MECHANICALLY COMPACTED, OR ON A 6 INCH CRUSHED STONE BASE. 3.) SEPTICTANK(S) SHALL MEET ASTM STANDARD C1127-93 AND SHALL HAVE AT LEASTTHREE 20" DIAMETER MANHOLES. THE MINIMUM DEPTH FROM THE BOT11 - DEPTH FROM SURFACE (INCHES) 0-24 SOIL HORIZON A SOIL TEXTURE (USDA) FINE LOAMY SAND SOIL COLOR (MUNSELL) 10YR 3/2 SOIL MOTTLING NONE OTHER 24-47 B FINE LOAMY SAND 10YR 5/8 NONE 47-63 C1 I FINE LOAMY SAND 10YR 5/8 1 NONE 63-78 C2 BOG IRON 10YR 3/1 1 NONE VERY FIRM 78-104 C3 SILT LOAM 10YR 6/1 NONE FIRM 104-152 C4 LOAMY MED. TO CRS. SAND 10YR 413 NONE 15% GRAVEL; 5% COBBLES TOM OF THE SEPTIC TANK TO THE FLOW LINE SHALL BE 48 . 4.) SCHEDULE 40 PVC INLET AND OUTLET TEES SHALL EXTEND A MINIMUM OF 6" DATE OF TESTING: 9-16-2021 ABOVE THE FLOW LINE OF THE SEPTIC TANKAND SHALL BE INSTALLED ON THE PERCOLATION RATE: LESS THAN 5 MIN/INCH IN C3 LAYER OF TH1 AND C4 LAYER OF TH2. CENTERLINE OF THE TANK DIRECTLY UNDER THE CLEANOUT MANHOLE. WITNESSED BY: MATT WROBEL, EIT, J.M. O'REILLY & ASSOCIATES, INC. AMYVON HONE, HEALTH DIRECTOR 5.) RAISE COVERS OF THE SEPTIC TANK AND DISTRIBUTION BOX WITH PRECAST NO WATER ENCOUNTERED CONCRETE WATERTIGHT RISERS OVER INLET AND OUTLET TEES TO WITHIN 6" OF USEA LOADING RATE OF 0.74 GPD/SF FOR SIZING OF SOIL ABSORPTION SYSTEM. FINISH GRADE, OR AS APPROVED BY THE LOCAL BOARD OF HEALTH AGENT. 25.0' 6.) PIPING SHALLCONSIST OF 4" SCHEDULE 40 PVC OR EQUIVALENT. PIPE SHALL BE LAID ON A MINIMUM CONTINUOUS GRADE OF NOT LESS THAN 1%. 4.0' 8.5' 8.5' 4.0' 7.) DISTRIBUTION LINES FOR SOIL ABSORPTION SYSTEM (AS REQUIRED) SHALL BE 4' DIAMETER SCHEDULE 40 PVC LAID AT 0.005 FT/FT. LINE SHALL BE CAPPED AT END OR AS NOTED. 8.) OUTLET PIPES FROM DISTRIBUTION BOX SHALL REMAIN LEVEL FOR AT LEAST 2' BEFORE PITCHING TO SOIL ABSORPTION SYSTEM. WATER TEST DISTRIBUTION BOXTO ASSURE EVEN DISTRIBUTION. q v 9.) DISTRIBUTION BOX SHALL HAVE A MINIMUM SUMP OF 6" MEASURED BELOW THE OUTLET INVERT. ro m 10.) BASE AGGREGATE FOR THE LEACHING FACILITY SHALL CONSIST OF 3/4" TO N4 1-1/2" DOUBLE WASHED NATIVE STONE FREE OF IRON, FINES AND DUSTAND SHALL BE INSTALLED BELOW THE CROWN OF THE DISTRIBUTION LINE TO THE BOTTOM OF THE SOILABSORPTION SYSTEM. BASE AGGREGATE SHALL BE COVERED WITH A 2" LAYER OF 1/8" TO 1/2" DOUBLE WASHED NATIVE STONE FREE OF IRON, FINES AND DUST. 11.) VENT SOIL ABSORPTION SYSTEM WHEN DISTRIBUTION LINES EXCEED 50 FEET, WHEN LOCATED EITHER IN WHOLE OR IN PART UNDER DRIVEWAYS, PARKING AREAS, TURNING AREAS OR OTHER IMPERVIOUS MATERIAL, OR WHEN PRESSURE DOSED. 12.) SOILABSORPTION SYSTEM SHALL BE COVERED WITH A MINIMUM OF 9" OF CLEAN MEDIUM SAND (EXCLUDING TOPSOIL). 13.) FINISH GRADE SHALL BE A MAXIMUM OF 36" OVER THE TOP OF ALL SYSTEM COMPONENTS, INCLUDING THE SEPTIC TANK, DISTRIBUTION BOX, DOSING CHAMBER SCALE: 1" =10' I AND SOILABSORPTION SYSTEM. SEPTIC TANKS SHALL HAVE A MINIMUM COVER OF 9". 14 rFROM THE DATE OF INSTALLATION Of -THE SOIL ABSORPTION SYSTEM UNTIL RECEIPT OF A CERTIFICATE OF COMPLIANCE, THE PERIMETER OF THE SOIL ABSORP- TION SYSTEM SHALL BE STAKED AND FLAGGED TO PREVENT THE USE OF SUCH AREA FOR ALLACTMITIES THAT MIGHT DAMAGE THE SYSTEM. 15.) EXISTING 1,000 GALLON SEPTIC TANK: THE INSTALLER SHALL REMOVE EXISTING TEES WITHIN THE TANK. NEW TEES WITH OUTLET GAS BAFFLE SHALL BE INSTALLED. THE DIMENSIONS OF THE TEES SHALL BE AS SHOWN ON FLOW PROFILE. 16.) EXISTING LEACH PIT: THE EXISTING LEACH PITSHALL BE PUMPED FILLED AND ABANDONED OR REMOVED. 17.) SOIL REMOVAL: ALLTOPSOIL, SUBSOIL, LOAMY FINE SAND, SILT LOAM AND BOG IRON (REFER TO SOIL LOGS) SHALL BE REMOVED FOR A DISTANCE OF 5 FEET FROM THE SOIL ABSORPTION SYSTEM (SAS) AND DOWN TO THE LOAMY MEDIUM TO COARSE SAND. THE EXCAVATION SHALL BE BACKFILLED WITH CLEAN "TITLE 5" SAND, COMPACTED TO MINIMIZE SETTLEMENT. 18.) LOCATION OF EXISTING LEACH PIT WAS TAKEN FROM THE AS -BUILT CARD ON FILE WITH THE BREWSTER HEALTH DEPARTMENT. INSPECTION NOTE: PRIOR TO FINAL INSPECTION BY TH E ENGINEER, SYSTEM N EEDS TO BE COMPLETE INCLUDING BUILDUP FOR COVERS. FLOW PROFILE: TOTAL OF FOUR(4) COVERS TO WITHIN 61NCHES OF FINISH GRADE; NOT TO SCALE TWO ON SEPTIC TANK, ONE ON D -BOX AND ONE ON SAS 20 DIAMETER CONCRETE COVERS RAISED TO WITHIN 6" OF FINISH TOP OF FOUNDATION GRADE (OR AS NOTED) EL= (SEE NOTE#5) Proposed EL= SAS PLAN VIEW 0 EXISTING 1,000 GALLON SEPTIC TANK TO REMAIN DB -3 D -BOX H-20 EXISTING I PROPOSED KITCHEN & I """" DINNING BR#1 D UNINGROOM FIRST FLOOR (NTS) BATH STORAGE ATTIC HALL BR#3 I BR#2 / Brewster, E 101. MA 14,. NG SEWAGE DESIGN FLOWi 3T 3 BEDROOM DWELLING @ 110 GPD = 330 D T 4`0" GAS BAFFLE - EXISTING 1,000 GALLON SEPTIC TANK TO REMAIN DB -3 D -BOX H-20 EXISTING I PROPOSED KITCHEN & I """" DINNING BR#1 D UNINGROOM FIRST FLOOR (NTS) BATH STORAGE ATTIC HALL BR#3 I BR#2 / Brewster, MA SYSTEM DESIGN C LCULATI S: SEWAGE DESIGN FLOWi 3 BEDROOM DWELLING @ 110 GPD = 330 D LEACHING CAPACITY REQUIREM3 BEDROOMS MAX. @ 110 GPD = 330 D REQUIRED SEPTIC TANK CAPACITY REQUIREM DAIL F W = PD 20 = 660 AL. REQUIRED SEPTIC TANK CAPACITY PROVIDEDi 4Route EXISTING 1,000 GALLON SPETIC TAN TO REMAINLEACHING CAPACITY PROVIDEDi in street ONE 1 2. LEAH G CHAMBER CAN L CH:Vt=[(25.0 X 12.83) + (25.0 X 2.0)2 (12.83X2.0)2]X0.7 GPD/SF=349.3GPD 349GPD>330GPD EQUIRED NOTE: A GARBAGE DISPOSAL I NOT PERMITTED WI THIS DESIGN_ INSTALD ONE (1)- 3 OUTLET DISTRIBUTION BOX (H-20 Rate TWO (2)-500 GALLON LEA CHAMBERS WITH 4' F NATIVE STONE ALLAROUND toa NOT TO SCALE tL 48.5 00 CD 48.3 PLAN BOOK 268 PAGE 73 48.3 °o DEED BOOK 32293 PAGE 163 •5 m ASSESSORS' MAP 90 PARCEL 63 ca a so 3 Utility Pole LEGEND 48.4 EXISTING CONTOUR " 48.3 PARCEL63 32 PROPOSED CONTOUR X1234 EXISTING SPOT GRADE AREA= 26,000 SF± 24x5 PROPOSED SPOT GRADE 48. 48.5 (PER ASSESSOR'S RECORDS) - Nq___ WATER SERVICE LINE -o- OVERHEAD UTILITY SERVICE 6 -U- UNDERGROUND UTILITY SERVICE 48.5 Existing O� - G- GAS SERVICE LINE Gravel Driveway 48.3 01 TEST HOLE / BORING LOCATION ST SEPTICTANK 48.4 48.3 DB DISTRIBUTION BOX 1.0 49.0 8.7 48.5 SAS SOILABSORPTION SYSTEM ® Reserve RESERVED FOR FUTURE 48.4 487 UTILITY POLE \,48.8 x 48.8 -Shed CATCH D CATCH BASIN FIRE HYDRANT R WELL �% Op x 48.8 x 48.7 DRAINAGE MANHOLE 48.9 ■ CONCRETE BOUND, FOUND _ x 49.1 49. - ._ - - - -- - - TOP -OF BANK-- LIMIT ANK LIMIT OF WORK -- 49.5 FENCE 01�'I//(/ X 49.4 49.5 x 49.6 EDGE OF CLEARING NT 49.4 `Q® NOTE: THIS PLAN IS INTENDED FOR USE AS A SEWAGE SYSTEM 0 x 49.2 qj 0 --- PLAN AND DOES NOT REPRESENTA PROPERTY BOUNDARY o L,� c,� 'ic `- 49.1 SURVEY. THE PROPERTY SHOWN HERE ON IS THE PARCEL a°, TP DBOX 49.5 - „'o a �o� DESCRIBED IN DEED BOOK 32293, PAGE 163. a 2 =V m�\� am O x 49.6 yy 49.6 �� �� -N2 Jap r x 5 .1 �h �4� } �o 49.5 w TH1 `� f' ,to a . G�5 X49.5' ; 11 LP 050.0 x 49.0 SECOND FLOOR (NTS) "' 12" Maples ,. x 49.5 y FLOOR PLANS 16" Maple x 4 4 50.9 51.3 �10' Pine 12" Maple 11 50.2'. 51.2 50 PROPOSED VENT f 36 MIN 3± 50.4 , ti, Permit valid for REPAIR OF SEPTIC SYSTEM ONLY, due to State and Local septic variances. Board of Health review and 49.5 approval is required for any future additions/renovations/alterations x 49.1 to sewage facilities and/or structures/dwelling. I Brewster Health Department JL40 Existing 1,000 Gallon Septic Tank pR TO REMAIN -17�*s Inlet Invert EL=45.5± 6 � -- Outlet Invert EL=45.3± 4OKarne Date VARIANCE REQUESTED: _ 52"±Proposed 45.0± SOILABSORPTION DEPTH BELOW GRADE: 54 INCHES OF COVER PROVIDED; 18 INCH VARIANCE REQUESTED 2" LAYER OF 1/8"-1/2" NATIVE STONE 44.00 0 '� 3/4"-1-1/2" NATIVE STONE OF�� 44.23 2" DROP 42.00 OTA EiLLY USE TWO (2) SHOREY PRECAST c 4 V CIVIL 500 GALLON LEACH CHAMBERS 5.3`± NO. Se 00 Both Runs WITH 4' OF NATIVE STONE AROUND -11'± LEACHINGvCHAMBER -EL=36.7± BOTTOM OF TEST HOLE 0 2�1 NAL 60 25.0'x 12.83'x 2.0' (H-20 RATED UNITS) SCALE 1"=20' G-.\AAJobs\Paul Daley\9169\dwg\9169SDS Plan.dwg REVISED 10 4-2021: ADED VENTTO S.D.S DALEY INVESTMENT REALTY TRUST PAUL DALEY, TRUSTEE, P.O. BOX 178, BREWSTER, MA 02631 SITE & SEWAGE DISPOSAL SYSTEM DESIGN 34 WINSLOW LANDING ROAD, BREWSTER, MA J.M. ' EIUY & ASSOCIATES, INC. Professional Engineering & Land Surveying Services 1573 Main Street - Route 6A P.O. Bos 1773 (508)896-6601 Office Brewster, MA 02631 (508)896-6602 Fax I t: SCALE: BY: CHECK: JOB NUMBER: 9-28-2021 1 As Noted I jmo I JMO I JMO-9169 1 ARCHITECTURAL ASSOCIATES 145 South Street Boston, MA 02111 T 617.357.7171 www.beaconarch.com © 2021 JDT Investments, LLC 21 Wormwood, Suite 402 Boston, MA 02210 PROJECT KITCHEN CAFE BREWSTER 2 671 MAIN STREET, BREWSTER MA JOB NUMBER 20-814 SCALE 1/2 If = 1 '-0" DRAWING NAME Kitchen Equipment & Basement Plan DRAWING NO. ISSUE DATES DATE BY 05-14-2021 • DESCRIPTION • Permit Set JDT Investments, LLC 21 Wormwood, Suite 402 Boston, MA 02210 PROJECT KITCHEN CAFE BREWSTER 2 671 MAIN STREET, BREWSTER MA JOB NUMBER 20-814 SCALE 1/2 If = 1 '-0" DRAWING NAME Kitchen Equipment & Basement Plan DRAWING NO.