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HomeMy WebLinkAbout0007 EEL RIVER ROAD - Health 7 EEL R-JVX -R"ROAD RV ILLE A = 116 104 o ° E i I ,, I No. Zoo, .57 7 Fee THE COMMONWEALTH COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS ZIpprication for Migonl 6petem Construction Vermit Application for a Permit to Construct( . )Repair( )Upgrade( )Abandon 9). ❑Complete System ❑Individual Components Location Address or Lot No. .7 C;b7-. R—i V61-1 J20- Owner's Name,Address w.W Tel.No. Assessor's Map/Parcel Installer's Name,Address,and Tel.No. PAS'TbQZ C-7fC.AVAT1 Designer's Name,Address and Tel.No. Po 6o4 1Z89 1=o�'DAUIS OB 2 93a o Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) AQ AI-YDQt,) 1)0 U�Ffl c'ss''s P6-L_ Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the nvironmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this�Bo o lth. Signed / Date Z" Z'�`� Application Approved by e, Date /Z Application Disapproved for th llowing reasons Permit No. Date Issued -- _--_------___------__�_-- TOWN OF BARNSTABLE- LOCATION G�I C 1VGr R� SEWAGE# VILLAGE 0 S'r rv,[U, ' ASSESSOR'S MAP&PARCEL INSTALLERS NAME&PHONE NO. SEPTIC TANK CAPACITY .5U0 S,nG CES1AOD LEACHING FACILITY:(type) 4' t'IOW S (size) NO.OF BEDROOMS OWNER I44'ro S61 PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY ^s F 6t EL 9 v b � vv I2I�y �.00� .f- No. S7 ( Fee s / THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: �Z PUBLIC HEALTH DIVISION -\TOWN OF BARNSTABLE, MASSACHUSETTS Yes 01ppYication for Mi.5po9;al*V!5tem Construction Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon ) ❑Complete System ❑Individual Components Location Address or Lot No. -7 G Sj.- Qi V 60 /20. Owner's Name,Address aµ¢_Te1 No. 'Os-m-mV,l. Assessor's Map/Parcel g/Ld�A/tl , Installer's Name,Address;and Tel.No. }>AST6 QZ CX(AV/Nn Designer's Name,Address and Tel.No. Y; P 0 503 42e— 9300 Type of Building: Dwe 11in No.of Bedrooms Lot Size s9 .. Garbage Grinder( ) `, "'-'Other g Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) AQ/1N�Qt.) U 0 05"61 CSS hfTZSL Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore,described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Boar;I�e7alth. r Signed Nr... Date Z Z3 d ' Application Approved by Date /Z' ` Application Disapproved for th�ollowing reasons 1 R' Permit No. Z D Date Issued. Z y dS _ 1 _ j ✓���t� �� „� un THE COMMONWEALTH OF MASSACHUSETTS ct� BARNSTABLE, MASSACHUSETTS - s�� Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired ( )Upgraded( ) Abandoned a)by PAST Un 'Z;)t C,N V�l-t it'r° at c�;gt 1 -1 V Fa2 � �-�/�u-� has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. L1f dated / 2 f9 + rt Installer aJTac�" �CGY>V"Y�" �+r-�1 Designer The issuance of thist permit shall not be construed as a guarantee that the system 11 function as esi tied. Date 1�1 A yI1 n V. Inspector 1 I ff ..---------------------------- No. �5 Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION- BARNSTABLE, MASSACHUSETTS )JOi5pogar *pgtem Construction Vermit Permission is hereby granted to Construct( )Repair( ')Upgrade( )Abandon System located at -7 i;°mot and as described in the above.Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Cons uction in st be completed,within three years of the date of this permit. Date:_ 22 y Approved b - '' PP Y COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 7 Eel River Road. Osterville. MA 02655 Owner's Namei Cynthia.& George Harrison Owner's Address: Date of Inspection: December 8. 2008 Name of Inspector: (Please Print) Jaynes M. Ford Company Name: James M. Ford Mailing Address: P.O.'Box 49 Osterville,MA 02655-0049 Telephone Number: (508)862-9400 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.. The.inspection was performed based on my training and experience in.the proper function and maintenance:of on site sewage disposal systems. I am a DEP approved system inspector.pursuant to Section 15.340 of Title 5(310.CMR 15.000). The system: ✓ Passes,-see comments pg2 Conditionally Passes . .. Needs Further.Evaluation by the Local Approving Authority Fails Single cesspool Inspector's Signature:. Date: December 17,2008 The system inspector shall submit a copy of this inspection report to the Approving.Authority(Board of Health or DEP)within 30 days of completing.this inspection: If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector-and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent.to the buyer, if applicable,and the approving authority. . Notes and Continents . ****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. Title 5 Inspection Form 6715/2000` page-1- Page 2 of-,1I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 7 Eel River Road Osterville, MA Owner's Name;' Cynthia& George Harrison Date of Inspection:- December 8. 2008 Inspection Summary: - Check A,B,C,D or E./ALWAYS complete all of Section D A. System Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303.or in.310 CMR 15.304.exist. Any failure criteria not evaluated are,indicated below. Comments: ' r but might be under sized do to the number o bedrooms. The system in rout and had no visual si hs o failure b T v � v g if g � of bedrooms. single cesspool in the back yard that servers the kitchen automatically fails in the town of Barnstable. B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined",please explain. The septic tank is metal and over 20 years old* orthe septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,.not leaking and if a Certificate.of Compliance indicating that the tank is less than 20 years,old is.available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,.settled or uneven distribution box. System will.pass inspection if (with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution'box is leveled or replaced. ND.explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 is 'Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 7 Eel River Road Osterville, MA Owner's Name: Cynthia& George Harrison Date of Inspection: December 8. 2008 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to.determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CAM 15.303(1)(b)that the system is not functioning in a manner which will.protect public health,safety and the environment: _ Cesspool or privy is50 feet of a surface water Cesspool or privy is.within'50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the. system is functioning in a manner that protects the public health,safety and environment: The system has a septic.tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or.tributary to a.surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a.public water supply. The system has aseptic tank and SAS and the SAS is mithin 50 feet of.a private water supply well. The system has aseptic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water.supply well". Method used to determine distance **This system passes if the well water analysis;performed at a DEP.certified laboratory, for coliform bacteria'and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided.that no other failure criteria are triggered. A copy of the analysis must be.attached to this form. 3. Other: Page 4.of I l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A : CERTIFICATION (continued) Property Address:-' 7 Eel River Road Osterville. MA Owner's Name: Cynthia&GeorQe Harrison Date of Inspection: December 8: 2008 D. System Failure Criteria applicable to all systems: You must indicate either"yes"or"no"to each of the following for all inspections: Yes No ✓ Backup of sewage into facility or system component due to.overloaded or clogged SAS or cesspool ✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspoot ✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number. of tunes pumped_. . ✓ Any portion of the SAS,cesspool or privy is below high ground water elevation. ✓ Anyportion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ✓ Any portion of a cesspool or privy is within a Zone 1 of a public well. ✓: Any portion of a cesspool or privyis within 50 feet of a private water supply well. _ ✓ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality.analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile.organic compounds indicates that the.well is free from pollution.from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria . are triggered:' A copy of the analysis must be attached to this form.] Yes (Yes/No)The system,fails. I have:determined that.one or more o f the above failure criteria exist as described in 31O CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to detennine.whai will be necessary to correct the failure. Note,kitchen.flows to a single cesspool.in back yard E. Large System: To be considered a large system the system must serve a.facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: .(The following criteria apply to large systems in addition to.the criteria above) Yes No .: the system is within 400 feet of a surface drinking water supply _ the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the.large system has:failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regionat office of the Department. 4 Page 5 of 11 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 7 Eel River Road Osterville.,ILIA Owner's Name: Cynthia& George Harrison Date of Inspection: December 8, 2008 Check if the following have.been done: You must indicate"yes"or"no"as to-each of the following: Yes No ✓ Pumping information was provided by the owner;occupant;or Board of Health ✓ Were any of the system components pumped:out in the previous two weeks? Has the.system.received normal flows in the previous two week period? . Have large volumes of water been introduced to the system recently,or as part of this inspection? ✓ - Were as built plans of the system obtained and examined?(If they were not available note as N/A) ✓ Was the facility or dwelling inspected for signs of sewage back up? ✓ _ Was the site inspected.for signs of break out? ✓ _ Were all system components,excluding the SAS,located on site? ✓ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,.depth of liquid,depth of sludge and depth of scum? Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal.systems The size and location of the Soil Absorption System'(SAS)on the site.has been determined based on: Yes No ✓ Existing information. For example.,a plan at the Board of Health. ✓ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)]. 5 Page.6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 7 Eel River Road Osterville, MA Owner's Name: Cynthia&George Harrison Date of Inspection:_ December 8, 2008 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): N1a Number of bedrooms(actual): 7-per town records DESIGN flow based on 310 CMR 15.203 (for.example: 110 gpd x#.of bedrooms): N/a Number of current residents: 0 Does residence have.agarbage grinder(yes or no): n/a Is laundry on a separate sewage system(yes or no): n1a. [if yes separate inspection required] Laundry system inspected(yes or no)' No Seasonal use(yes or no): No Water meter readings, if available(last 2 years usage(gpd)): Unavailable Sump Pump(yes or no): No Last date of occupancy. Sunnnrer/week end COMMERCIALANDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Bas is of design,flow(seats/ ersons/s ft,etc. p 9 ) Grease trap present(yes or no): Industrial waste holding tank present(yes or no) Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings, if available: Last date of occupancy/use: .- OTHER(describe): GENERAL INFORMATION Pumping Records. Source of information: unavailable Was system pumped as part of the inspection(yes or no): If yes,-volume pumped:.._gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM ✓ Septic tank,distribution box,soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes,aitach previous inspection records,if any) Innovative/Alternative.technology. 'Attach'A copy of the.current operation and maintenance contract(to be obtained from system owner) Tight Tank Attach a copy of the DEP approval Other(describe):; Approximate age of all components,date installed(if known)and source of information: Unknown . , Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEMINSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 7 Eel River Road Osterville. MA, Owner's Name: Cynthia& George Harrison Date of Inspection: . December 8, 2008 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron 40 PVC _other(explain):. Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ✓ locate on site lam ( plan) Depth-below grade:.. 8" Material of construction: ✓ concrete _metal fiberglass _polyethylene other(explain) If tank-is metal list age: Is,age confirmed bya Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 1500 oral. Sludge depth: 2;, Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: 3 Distance from top.of scum to top of outlet tee or baffler 6" Distance from bottom of scum to bottom of outlet tee or baffle: 10" How were dimensions determined: Measurinz stick Connnents(on pumping recommendations,inlet and outlet tee or baffle condition„structural integrity,liquid levels as related to outlet invert;evidence of leakage,etc.): Tees were present. The liquid level was even with the outlet invert." There did not appear to be any signs of leakage GREASE TRAP: None (locate on site plan) Depth below grade: Material of construction: _concrete _metal fiberglass._polyethylene _other (explain): . Dimensions: Scum thickness: ; Distance from top of scum to top of outlet tee or baffle: Distance froin bottom of scum to bottom of outlet tee or baffler Date of last pumping: Comments(on pumping recommendations,inlet and outlet,tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.):. 7 Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 7 Eel River Road Ostuville, MA Owner's Name: Cynthia& GeorQe Harrison Date of Inspection: December 8, 2008 TIGHT or.HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: _concrete _metal._fiberglass _polyethylene _other(explain): Dimensions: Capacity: gallons - Design Flow: gallons/day, Alarn present(yes or no): Alarm level: Alarm in working order(yes or no): .-Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: ✓ (if presentmust be opened)(locate on;site plan) Depth of liquid level above outlet invert:, Even 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.): The D-box was clean. No solids were present. PUMP CHAMBER: . None (locate on site plan) Pumps in working order(yes or no): F Alarms in�working order(yes or no) Comments'.(note condition of pump chainber;condition of pumps and appurtenances,etc.): 8 Page 9 of l 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 7 Eel River Road Osterville, MA Owner's Name: Cynthia& George Harrison Date of Inspection: December 8, 2008 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not;located explain why: Type. leaching pits,number: leaching chambers,number; leaching galleries,number: 4-Flow Diffusors-usors-per as-built leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: Innovative/alternative system. Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): The Flows`Diffusors were dry and clean. There did not appear to be any signs of failure.A camera was used for'the inspection CESSPOOLS: ✓ (cesspool must be.pumped a'sj part of inspection)(locate on siteplan) Number and configuration: 1 single for the kitchen Depth-top of liquid to inlet invert:. Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials-of construction: 600 gal.pit Indication.of groundwater inflow(yes or no): Comments'(note.condition of soil;_signs of hydraulic failure,level of ponding,condition of vegetation,etc.): The single cesspool serves the kitchen sink. The cover is to grade in back yard. PRIVY: None _(locate on site plan) t Materials of construction: Dimensions: Depth of solids: Commments(note condition of soil,,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): 9 Page 10'of 11' OFFICIAL INSPECTION FORM-:NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:. 7 Eel River Road Osterville,MA Owner's.Namei . Cvnthia:&George Harrison Date of Inspection: December 8, 2008 SKETCH OF SEWAGE`DISPOSAL SYSTEM :Provide a sketch-of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate wher e public water supply enters the building.Al Covtr S�A� 13 at a { a- a a3 ILI a.9 10 Page 11 of 11 OFFICIAL INSPECTION FORM.-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) .Property Address 7 Eel River Road Ostervilie, MA Owner's Name: Cynthia& George Harrison- Date of Inspection: December 8. 2008 SITE EXAM Slope Surface water Check cellar Shallow-wells Estimated depth to ground water 8+/- feet Please indicate(check)all methods used to determine the high ground water.elevation: Obtained.from:system design plans on record-If checked;date of design plan reviewed: Observed site(abutting properly/observation hole within 150 feet of SAS) ✓ Checked'with local Board of Health-explain: Topographic and water contours maps Checked with local excavators,installers-(attach documentation) ` Accessed USGS database-explain: You must describe how you established the high ground water elevation: The bottom of the flow diffusors to y rade was 40" I hand augured down to 6'below jzrade no water was observed. There is no water djusttnent for this site Tidal bay is within'500' • f This report has been prepared only for the septic system and components described herein. This septic system has been inspected and passed as of the date of inspection. This report is not a warranty,or guarantee that the system will function properly in the future. There have.been no warranties or guarantees, either expressed written or implied, relating to the septic system, the-inspection, this report and/or any components of the septic system which.have not been located and inspected... • _ 11 • MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING . City/Town: ,�.... �t MA. Date:liPermit# 5 �. ... Building Locationa� vvi//L wners Name: .Type of Occupancy: Commercial 1. Educational I Industrial L Institutional o Residential New:1.y Alteration: tenovation: Replacement:�� Plans Submitted: Yes Noc FIXTURES r2,A z CO O 0- z QQ N zf- y - az N Qz w co w CO N . O, a UJ UJ HLLX? z W co V ILQ zQ W Y = W0 x uO O a Y a x w w w QN .w aV 0 _ O QO Q. 0 Q ❑ ❑ u � R." Oop 9 - rM SUB BSMT. BASEMENT 1 FLOOR 'a 2 FLOOR: c� 3 K u FLOOR' 4 1H FLOOD CT 51H FLOORR% 6 FLOOR 7 FLOOR f 8 FLOOR Check One Only Certificate# Installing Company Name:, Corporation e Address: —� r' i City/Town � GState: M I A �'"�"-lw � L�� , r—�-� _ ILm9 Partnership -- Business Tel: Fax:Fax: �e, D-F �m/CompanyName of Licensed Plumber INSURANCE COVERAGE: I have a current liabili insurance policy or its substantial equivalent which meets the requirements of MGL.Ch. 142 Yes, E If you have checked Yes,please indicate the type of coverage by checking the appropriate box below. A liability insurance policy i Other type of indemnity 1« Bond OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on-this permit application waives this requirement. Check One Only C Signature of Owner or Owner's Owner Agent A ent - I hereby certify.that.all of the details and information I have submitted(or entered)regarding this application are true and accurate to the best of my Knowledge and that all plumbing work and Installations performed under the permit issued for this application will be in compliance with all Pertinent.provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. Type of License: Titlel v t ✓ plumber Signature pft`icensed Plumber Master Cityrrown (_ Journeyman �y License Number: l��c�/ l APPROVED`OFFICE USE ONEY7J'�'� i �-�.�- � � - � � - (� � _� 1 � .. - f +:. _ �� � � .� / 1 _ - ,� /� �. V o ' �� /�, r �; .. �1i'"�/ ;,,\ ., {� - � ' Town of Barnstable Assessors Division Page 3 of 3 jaD17�i7:... F: aclt -Forward Home Departments Town Information Contact Town Hall Website Developed and Maintained internally by the Town of Barnstable Information Systems Department Town Hall-367 Main Street- Hyannis,MA-02601 -508-8624000 DISCLAIMER: Although we strive to provide accurate information,we are only human. Please consult directly with the appropriate department if there is a question of accuracy. Copyright 2001©Town of Barnstable. All Rights Reserved. http://www.town.bamstable.ma.us/ComeOnIn/Departments/Administrative_Services/Finan... 1/14/2002 i DAT13;.� 9/6 00---- PROPERTY ADDRESS:-..---- ------------------ 7 Eel River Road _-Osterville on the above date, I Inspected the septlo system at the above address. This system conslsts of the following: 1 . 1 -1500 gallon septic tank 2. 4-f o-diffusors. 3. 1 -5M. Cesspool seperate Based on my Inspectlon, I certify the following oondltlons; / - U 4. This is a title five septic system. ( 78 Code ) 5. There is a ,separate. cesspool for the kitchen. 6.' The septic and sewage system are in proper working order at the present time. , ' - -7.� The cesspool _arid flow diffussors are dry at the present time. SIGNATURE:,f Company,�0J!.2h_t----- ---- ,b Son , Inc . Address;_ Box-66-- __Centerville L Na`_02632-0066 Phone:___ 28_775_9398_-_---- THIS CERTIFICATION DOES NOT CONSTITUTE A C)VARANTY OR WARRANTY JOSEPH P. MACOMBER & SON, INC. Tanks•Cesspools•Leachflolds.. Pumped L Installed Town sewer Connections P.O. Box 6775.3338erY77, MA 02632.0066 .0 C Z e COMMONWEALTH OF MASSACHUSETTS ' f EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENviRoNrm=AL PROTECTION ONE WINTER STREET, BOSTON MA 02108 (617) 292.6600 TRUDY COXCE . Secr+tiry ARGEO PAUL CELLUCCI DAVM B. STRUHS Govcrnor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Proper y Addr*,:7 Eel River Road Narrw of ownw Mrs Joseph Cronin Osterville Address of owner: Darts of Irsspectiort: q/6/0 0 Men" of hspector: 1 PArrUJoseph P. Macomber Jr. I am a DEP apprvwd systarn inspector pursuant to Sectlw 15.340 of Thie 6(310 CMR 15.000) C.O,T rykanw: Jose h P. Macomber & Son Inc. µ,XngAddrv&,: oCenterville, Ma . 02632-0066 Telephone kurnbw: CERTI.FiCAT10N STATEMENT i certify that I have personally Inspected the sewage dlsposal system at this address and that the Information reported below Is true, accurate and complete as of the time of inspection. The Inspection was performed based on my trolning and experience In the proper function and muntenance of on-site sewage disposal systems. The system: . L^, Passes , Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority _ Fails q L4 vector's Sigrurture: � u•p '// Data: The System Inspector shall submit a copy of this.lnspectlon report to the Approving Authority(Board of Health or DEP)whNn thirty (30) days of completing this Inspection, If the system Is a shared system or has a design flow of 10,000 gpd or greater,the Inspector and the system owner shall submit the report to the appropriate regional office of the Department or£nvironmsnttd Protection. The original should be sent to Vu system owner and copies sent to the buyer, If applicable, and the approving authority. NOTES AND COMMENTS I(MENFO S E P 18 2000 TC%-OF eAiNsrngV r kill", DEPT. revised 9/2/98 Page Iof11 " Printed on Recycled Paper , SU&SURYACE SEWAGE DISPOSAL SYSTEM CN3►£C110N FORM, PART A �* CFRTIRCAT10N (oondAU,041 f ogwTy Agar.,,; 7 Eel River Road, Osterville owr"r. Mrs. Joseph Cronin Dww wl +: 9/6/0 0 e,s I XMARY: Ch ck a e. C, o. D. - A•��SYP;�S .J_ I have not found any Information whIch Ind)cetes that any of the f&Hurt cond?doru described In 310 CMR 14.303 exist. Any faCu crttotis not evaluated are Indicated below, CO W14D : i, SYSTEU CONDITIONALLY PASSES: One a,more *yet am sompon•nu oa dosoribed In the 'C"4or►al►was'Saodon need to be replaced w repairod. The system. up• compledon.of the replacement w ropair,ea approved by the Loard of Huth, wW paw6. tomcat• yea no, or not detsrmined(Y. N, w NO). Doscrtbe bass of detorminadort In all Irtatartoes. If 'not determined', explain why not. The septic tank la metal, unless the owner w opwotw has provided the System{rupeo or with a Copy of o C4-- Acate or CompUance (artach•d) Indicating that the tank was Wta od within twenty(20)yew prior to Cite date of ttw tnap+cvo++ the sepdc tank, whether or not metal, Is stocked, etrueturoAy unwound, shows substantial tnFivation w exAlvetton. Or t failure Is Imminent, The system Will pass Inspection If the existing sepds tank Is replaced with a compllMp septic taro approved by the Board of Health. Sewage backup or breakout or high sudo water level observed In the dlstvlbution box Is due w broken of oba-vvcted pap ` or due to a broken, e•rded or uneven dletrlbution box. The System willpass Inspection If (wttlt approved of tl+e Board of vtit , N• ) • aced broken pips) we replaced p) obswcdon Is removed dletrtbudon box Is levelled w replaced ` • The synsm(equked purrtplrtginmv Hiatt-iow'dmes V"&rdus to broKenw cbrou otod Opals). T.ha vyess^+ wwvv— Impaction If (with approval of the io ard of Health)t broken pipe(l) we replaced obstruction Is removed revised 9/2/96 hte2of11 + SUBSURFACE SEWAGE DISPOSAL SYSTEM WSPECTION FORM ir PART A ' CERTIFICATION (cor*wod) P„pefTyAd6,e„; 7 Eel River Road, Osterville ownet: Mrs. Joseph Cronin o.ae al tnapecdcn: 9/6/0 0 C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Condrdons exist which require further •vsJuadon by the Board of Health In order to determine If the system Is ftt11in9 to protect the public health. safety and the environment. 1) SYSTVA WILL PASS UNLESS BOARD OF HEALTH DETMMINES W ACCORDANCE WITH 310 CUR 16.303(1)(b)THAT THE SYSTE W 13NOT FUNCT10NW0 IN A MANNER WHJCJ{WILL.PAfjWT THE PUBLIC HEALTRAND SAFETY AUD THE E)1Z8OkIi1 3 to Cesspool or privy Is within 50 feel of surface water Cesspool or privy Is within 60 feet of a bordering vegetated wetland or a sell marsh. 2) SYSTVA WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF A)M DETFRUNiE3 THAT THE SYSTBI 13 ��FU}}NCTIONWO IN A mANNER THAT PROTECTS THE PUBLIC HEALTH AND sAFM AND THE EFIVIAONLLE 1T: ►1N The system has a septic tank and soil absorption system (SAS) and the SAS Is within 100 teen of a wrface water wpplY or ,^^ tributary to a surface water supply. ll�v The system he; a septic lank and soil absorption system and the SAS Is within a Zone I of a pubUc water supply well. The system has a septic lank and soil absorption system and the 3A3 la within 60 feet of a private wets, supply web. The system has a septic tank and soil absorption system and the SAS Is loss then 100 feet but 60 feet of mae hom a private wets, supply wall. unless a well water analysis for collform bectsrio and volatile organic compounds Indcates Mal v+. well Is free from pollution from that facility and the pr• ages of•mmonJo nitrogen end rtluste Nvogen Is equal to or less than 5 ppm. Method used to determine distance, 'pages (app(ozJrnrdon not vaUd).- 31 OTHER 1W revised 9/2/98 Page 3ofIt SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A ?, •, CERTIFICATION (corrtirwsd) Property Address: 7 Eel River Road, Osterville Owner: ' . Mrs. Joseph Cronin Oet.o+ n: 9/6/00 D. SYSTEM FAILS: youmu+t Indicate either -yes' or 'No' to each of the following: fai�() I have determined that one b�o or ofw. The the following lot i �Itnlsnouldnba contacteditons d to as det•rrN s what will be n c•ssmY to correct t1+• tulu determinatlon Is Id Yes No �1Sorc•4stod. {� Backup o4 sewage Into hclUtyror•K•tKtt oorttpon4nt'dcefto em overfoed�d orciegped _ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or cio9g*d SAS of coaspOOL Static liquid level in'the distrlbu o box ib- RuVat Invert due to an overloaded or clogged SAS or cesspod• . Liquid depth cesspool is less than 6' below Invert or'avallable volume Is less than 1/2 day flow. Required pumping more than 4 times.ln the laat Year ho du•to clogged or obatrvcted plDelsl. Number of time pumped )L. Any Donlon o1 the Soil Absorption System, cesspool or privy Is below the high groundwater elevation. Any portion of a cesspool or privy Is within 100 fast of a surface water supply or tributary to a surface water wpplY Any portion of a cesspool or privy is•wltfdn a Zone I of a public well. _ 1riv wlthln 60 toot of a private water supply well. Any portion of a cesspool or p Y Any portion of a cesspool or privy Is lost-than 100 feet but greater than 60 fast from a private water wPPIY weU w"M n Any pornotable water quality analysis. If the wall has been analyiad to be acceptable, sttach copy of wsU water snalYs's to acc—collform bacteria, volatile organlocompounds, ammonia nitrogen•and n+trats nitrogen. E. LARGE SYSTEM FAILS: You must Indicate either 'Yes' or *No' large' toa`h of e l o to the criteria above: e following:n The following criteria apply The system o and the environment because one or000 moropd of ol the following orge System) andcondition exist: syetom Is • slgrJflcant threat to health and Y Yes No/ _ !d/ the system Is within 400 toot of • surface drinking water supply the sy6tem.1e-wl04n 200 f49t ol♦-M ►tsryio suriaw dek+kirp'w+�"w►�Y the system Is located In a nitrogen sensitive area(Interim Wellhead Protection Area IWPA) or a mapped Zor+a a of • p —" water supply well) e system In accordance with 310 CMR 16.704(2), Pis+a•consult flee local fet The owner or operator of any such system shall upgrade th Office of the Department for further Inforrmadon. ' Psgt 4 of 11 revised 9/2/98 SUBSURFACE SEWAGE DISPOSAL 3Y3TEM INSPECTION FORM PART B . . CHECKLIST PropwlyAd&*&&- 7 Eel River Road, Osterville own«: Mrs. Joseph Cronin Deu of tnapectaon: 9/6/0 0 Check If the following have been done: You must Indicate either 'Yes' or 'No' as to each of the following: Yes No _✓ Pumping informstion was provided by the owner, occupant, or Board of Health. .(C -Nona of the system comoo&&nU ha+w-heors poenpad+bvacJaaatiwawaaka awdibe7Ystam h"Jwmav000l inansw A rates during that psrlod. Large volumes of water have not been Introduced Into the system recently or as pan of vvs Inspection. As built plans have been obtained and examined. Note If they are not available with NIA. _ The facility or dwelling was Inspected for signs of sewage backup. The system does not receive non•saNtary,or Industrial waste flow. The eke was Inspected foorr)signs of breakout. All system component the Soil.Absorption Systeml have been located on the site. _ The septic tank manholes were uncovered, opened, and the Interior of the septic tank was Inspected for condition of oat or tees, material of construction, dlmonslons, depth of liquid, depth of sludge, depth of scum. The &lie and location of the Soil Absorption System or►the alte has been determined based on: _ Existing Information. For example, Plan at B.O.H. _ Dstsrmined In the veld (If any of the failure crlterla related to Pan C Is at Issue, approximation of distance la unacceptao — 11 fi.302(31(bll The }ulUty owns (artd.or� p•^••,Jf dltfaraot frnM ^w^arl,satata.prafttdad.wtih Infarm.*lomon>��ur^ +- SubSurface Disposal Systems. revised 9/2/98 rtiieserll I SUBSURFACE SEWAGE DISPOSAL SYSTEM WSPECTION FORM PART C 3` ' SYSTEM WFORMATION P,w«ty Addrw: 7 Eel River Road, Osterville owrw: Mrs. Joseph Cronin Deoe of tr,ap.ctSon: 9/6/0 0 FLOW CONDITIONS RES00i TIAL; Design flow:_[(Q._g•p•d•1b dro m. Number of bedrooms (d slg Number of bedrooms(actual):Z Toni DESIGN flow Number of current residents: Garbage grinder(yes or no): _ Laundry(separate system) ( a Oro._; If yes, sepasatalnapactJomrequlrad Lwndry system Inspected_�i br no) � � �,� Seasonal use IY@s or nol: � ,r F /1 �5{ Water meter (@+dings,If av bl@ last two yews usage lgpol: `� SvmD D Y Pump (yes or no): Last date of occupancy: GOMMERCtALANDUSTRLAI; Type of estaWlshment: Design flow: d I Based on 16.203) Basis of design flow areas#trap present: (Yes or no) industrial Wasto Holding Tank present:(yes or no)A64 Non•saritary waste discharged to the Tltie 6 system: (yes or 604a _ Water moist resdings,If available: Last date of occupancy: A?A OTHER:(Describe) Lost date of occupancy: GENERAL INFORMATION VUIdPWG RECORDS nd source of'Informatlow? n System pumped as part of Inspection: IYes or no) 11 yes, volume pumped: gallons Reason for pumping: Ty F SYSTEM Septic tank/distribution box/soll absorption system Single cesspool Overflow cesspool Privy privy system(yes or no) (If yes, attach previous Inspection records,If any) Shared Technology ejjc. Attach copy of up to date operation and maintenance contract AJATight Tank 4IJ'! Copy of DEP Approval Other AQ A24 �.. APPRO +AGE o all components, djato Install iIf kn n7d a a�Al Sewage odor*detected when arriving at the site: (yes or no) revised 9/2/98 Page 6of11 TOWN OF BARNSTABLE LocA rJ TION L����/vex ?CQ4� SEWAGE VILLAGEnS )cr-/ kf ASSESSOR MAP & LOT . INSTALLERS NAME & PHONE NW_ I. Gcoo rs , LhG SEPTIC TANK CAPACITY o L LEACHING FACILITY:(tye y���/rili��Gl,�DIrS(size) NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER I BUILDER OR OWNER DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No e/ i S\b V a� Lr - • SUBSURFACE SEWAGE DISPOSAL'SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(corttirsued) Prop«h Address: 7 Eel River Road, Osterville Dwrw: Mrs. Joseph Cronin Data of Inspection: 9/6/0 0 Bu1LDING SEWER: (Locate on site plan) Depth below grade 'yAr !' p>/ r Material of swction e t Iron 0 PVx8o h r (e plain) Distance from rivate water sup I well or uction line Diameter Comments: (condition of Joints, venting, evidence of f"k"e, tc.l _,O( S 1711C TANK: b OL (locate on she plan) Depth below grader Material of construction: concrete4•meta14:�2Flberglass4/ Polyethylene Mother(explaln) If tank Is fnetal, I,l/i_o1g_e Ja.aoo.coyn1Vmed by Certificate of Compllance (Yes/No) Dimensionsva: �[l^ �'/1i�,, Sludge depth:f �— Distance from top sludge to bottom of outlet tee or trafflcj".'� Scum thickness: Distance from top of scum to top of outlet tee or,baffle: Distance from bonom of scum to bottom of outlet tee r _Me: Mow dimensions were dete►minid: Comments: . (recommendation for pumpin , condition of-inlet and outlet tees or-baffles, depth of liquid level in relation too, outlet invert, structu►el-integrily. evidence of le ka e, etc.)- ump septic tank and kii-r-be—ear �nglet & ou et t q at the outlet in The ana s ows no GREASE TRAP: (locate on site plan) Depth below grade: 44 Material of constructlonA concretaA�metal�FlberglassidApolyethyleneA2&other(explain) Dimensions: Scum tNckness: AM Distance from top of scum to top of outlet its or b@Mo:_A'!6 Distance from bonom of scum to bonom of outlet tee or,baMe:•td Dote of last pumping: AA Comments: (recommendation for pumping, condition of.Inlet and outlet tees or baffles, depth of liquid level In relation to outlet Invert, etructurat Ins W^T1. evidence of leakage, etc.) reas revised 9/2/98 Patr7of11 SU93URfACI SEWAGE D13PI03AL SYSTEU WSKMON FOFLU FAAT C SYSTVA WFORMATION IICOMn Property Ad*0": 7 Eel River Road, Osterville Ow-r-w: Mrs. Joseph Cronin O.Os of V ap.odon: 9/6/0 0 T1GW OA HOLDING TANX:m0 pink muet be pumped prior to, or at time of, Inspecdon) pocate on she plan) Otpth below pndC hleteriN of conawcNon:(�jytoncretenetaliberyl++l7�C,tdyethyleneVJjjliQfh+rl+xpi�nl YZ- Dimensions: C+D+cifow�VLX - 9Ilons Oe►ipn flow: p►Ilonsld+y Alarm present Alarm IerN: Alum,via, order:Yesl J� Now Oat• of previous pumpingl y= comments: lcondloon of INeI tee. sondltion of alum and float switches. etol Ina- "012 DL$TFtlev 10N SOX:/ luocale on W* pion) Depth of ligyld level above Oudel Invert:,. Comments: os•II level and distribution Is equal, evid9nnn of solids carryover, rAdonce of leakage Into 0,(out of logs. etc.) bi ibution F over. o ot the pump CMIABE7t:„1'M In'P— !locate on site Plan) pumps In working order:(Yea or No1�44 Alarms In working order (Yes or No) comments: Inote condition of pump chamber, condition of pumps and appurtenances, etc.) um 2 98 h{et ofll ed 9 revised / / SUBSURFACE SEWAGE DISPOSAL SYSTEM WSPECTION FORM PART C SYSTEM INFORMATION(con wod) Propert,Address: 7 Eel River Road, Osterville owner: Mrs. Joseph Cronin Deu of Inspection: 9/6//00 ` • p SOIL ABSORPTION SYSTEM(SAS):, f )U � � r�� (locate on site plan, If possible: excavation not required,location may be approximated by non-Intruslve methods) If not located, explain: Type: leaching pits, number: leeching chambers, num ber: . leaching galleries, numbs(: leaching trenches,number, ength: latching fields, number, dim•r slons: overflow cesspool, number: ' Alternative system: Name of Technology: Comments: ott condition of oil, signs of h Qroulic fall re, level of pon damp toll con o o} • eta n, etc. foamy santy to medium fine sand �� signs o° �iyc�au is ailure or q of s are arv.Vegetation - CESSP00 : (locate on site plan) Number end configuration: Depth top of liquid to Inlst Invert: JhV Depth of solids layer: Depth of scum layer: - Dimensions of cesspool: Materials of construction: Indication of groundwater: Inflow (cesspool must be pumped as part of Inspection) Did not pump cesspool resspnnl i —'d-y ni; tjaj r. tjfilqt Comments: (note condition of soil, signs of hydraulic failure, level of ponding,condition of-vegetation, etc.) Same as above Pam:4�qV E (locstt on site plan) Materials of construction: /f /9 Dlmenelons: Depth of sollds: Comments: (note condition of loll, signs of hydraulic failure, level of ponding, condition of vgetation, etc,) Privy revised 9/2/96 Psee9ofII 3Uf3U1trACi iCWAOtt Cts FAACfy9Tal Wi►tCnON f0� SySTvA WFOPWATION (pond--d) 7 Eel River Road, Osterville °"^"' Mrs. Joseph Cronin 9/6/00 5 SKr CH Of SEWAGE OISPOSAL SYSTEM: IncJ�Q� d�� to at Im%two pIrmanjnt n tnar l�r�nc�landkl of O,OR1 (AtO,h0U1�1 local# &I wollt wlthln too' (Locate who(#publlo watst wpaY 9- v ., Nk Q to revised 9/2/98 n:� f SUSSURFACE SEWAGE D p9sAL SYSTEM WS►ECT1ON FORM Sy PART C SYSTEM yjF %ORMA'nON (eon jod) draa �. .. p�op.rtyAda: 7 Eel River Road, Osterville Own«: Mrs. Joseph Cronin Date of V4P*ctson: 9/6/0 0 MRCS Report name Sou Type_ Typlc&J depth to groundwater USOS Date wobsite Ashod Ob&enatJon Wells checked Orovndweter depth: ShNlow Moderato Deep SITE EXAM Slope Surface water Chock Caller 3haJlow wells fjtmsted Dopth to Oroundwater/,L het ►Io;;;OI"'O%@Jnod dicate all the methods used to determine High Groundwater EJevatJon:hom Design Plans on record bserved Site (Abutting proper barrvation hole, bGOOM901 lump eta.) Irom locai condltlons Chocked with local Board of health Chocked FEMA Map& hocked pvmping records ^ /Chocked local a&cavators, Inst&Iler& -----iii��� Used USOS Date Describe how you e&tabushed the High Groundwater EJevadon, IMU11 ba completed) Used Cape Cod Water Table Contours and Public Water Supply Wellhead Protection Areas Map. September 1995 Water Resources Office Cape COd Commission G ' hiellofll revised 9/2/96 y i +wn..^wT1^1'+� wrwv•I...�rrTAnn+A'wnw+ww►PwA.'+^+A�^v►A'�n�w n'• A 'I'UNN OF BARNSTABT+F. BOARE) OF HEALTH 9U11SUItFnCF aexnc;P DISMSAL .SYSTEM INshECTION FORM -' PART D - CEItTiPICATIUN _. 1 ^ -TYPE OA PAINT CLCAALY- pl?OPERTY INSPECTED STREET ADDRESS 7 Eel River ASSESSORS HAP , BLOCK ANU PARCEL 1 1) OWNER' s NAME Mrs. Joseph Cronin PART D - CSItTIFICATIOK; NAME OF INSPECTOR Joseph P . Macomber Jr, COMPANY NAHE Joseph P. Macomber & Son Inc. nterville MA. 02632-0066 CO�IPANY ADDRESS Tovn or c ty >rt+t. t tr��t COHPAHY TELEPHONC ( 508 ) 775 - 3338 FAX CCR'rIFICATION STATEMENT I certify that I have personally inspected the sewage dieposa`1 system nt Drecoinmenda his nddress and that the information reported is true , accurate , and omplete as of the time of .inspection . The inspection was performed and any tloils regarding upgrade , maintenance , and repair are consistent with my training and experlence in the proper function and maintenance of on- site sewage disposal systems . „ Chec one ; ' System PASSED The inspection which I have conducted has not found any information which indicates that the system fails to adequately protect public jjejkj �jj a olteevaluntedcnt areaas defined stated in the FAILURE303 , Any CRITERIAfailtire section of criteria n this form . System FAILEUi on II The inspection which I have c acted has found that the system fails tc protect the jiublic health and the environment in accordance with Title 5 , 110 CHR 15 , 303 , and as specifically noted on PART C - FAILURE CRITERIA of this Inspection form . v Date Inspector Signature e opy of this a ification must be provided to the OWNER , the BUYER Dn wh•r. •VDllo�bl• ) and %,h. AOhRD OY }{gALZ'1l. y,I•. / the system • If th• Inspection PILED , thv owner or operator shall upgrade s of the inspection , unless allowed or required within - one year or the (Jot otherwise as provided In 3.10 ChIR 16 + 306 . partd +doc ... FR$....$....2.�.,.QQ. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ............ Town.............OF........B.a.r.neat.a.b.3.e.................................................. AV'firatiou for Bhop tia1 Work, 'Tilmitrurtiun ramit Application is hereby made for a Permit to Construct ( ) or Repair (X� an Individual Sewage Disposal System at: ......Off Eel River .... Oster.... .........._.. .... - Location-Address or Lot No. .....Mrs . Joseph._. r o n.],xi......................................... Owner Address ,W1 ► _..1?.xAId�DS�b�r.......................................................... -------•--..•...----......-----------.......-•--------•---.....-------•------..................... Installer Address Type of Building ,1 Size Lot............................Sq. feet U Dwelling—X No. of Bedrooms..-•-•-_----_ ---------------Expansion Attic ( ) Garbage Grinder ( ) �+ Other—Type T e of Building No. of persons............................ Showers — Cafeteria 114 YP g P ( ) ( ) A4 Other fixtures ................................. . W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity------------gallons Length................ Width................ Diameter---------------- Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area--______..____------sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ 14 Test Pit No. i................minutes per inch Depth of Test Pit.................... Depth to ground water-.___-_---_-_-_______-_- Gz, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ R+' •-•-••-----••••••-------•---•-•--------••-••-•-•-•-•••••....................................................................•••----••-••...........-•--...._. 0 Description of Soil........................................................................................................................................................................ x -----•-------------•------�a n.v --••-•--••-•......•-••-•-- -------------------•-------•------...----------------------------•-•-••••.. W -----•-----------------•---------------------------------------------------------------------------- ----------------------•---------------------------------------------------•-••-••---...._.....•••- VNature of Repairs or Alterations—Answer when applicable____-------1--.1_SQ-0---g-allnn_---bank................................. ----------•---------------------------------------------------•----•------...:.._...................-•-.._..•...... uaao r_S•••••••••......--•-•-------•-•-•••-- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iIT?:; 5 of the State Sanitary Code- The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued dhe/abo�f health. Signed•... . ..((°��// _---------- -----��- �8$...•...... Date Application Approved By............ "'„ --- -----••--•------------------ ------...5.. ------ Date Application Disapproved for the following reasons:-----•-----------------------------•--------------------------------------------------------------------..•---- ...................••-•••••-•-•••-----•--.....-----•----•-•----•---•---•-------••-•-----....-------•---•.-•••••••--•--•---------------------•-•--••--•---------••••-•---••----•---------••••--••-------- Date PermitNo.------.. --=-- t-t----•••---•------_. Issued....................................................... Date GG -I Fizz THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..................T.own............OF..........Ba.r.nata..b &.....----------------------.................---- Appliration for Disposal Worka Tnntrnrtion rrmit Application is hereby made for a Permit to Construct ( ) or Repair ( Xk an Individual Sewage Disposal System at: .......an;._Mal...Raup:r-...13oa.d...QaL exmille,Ifasr .d.............................................................................................. Location-Address or Lot No. ........................................ .................................................................................................. Owner Address a 3o.PP d<3�0 � ......................................................... .....---•--------...............................------...........-•---------...................... Installer Address Type of Building Size Lot............................Sq. feet V Dwelling -No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of persons............................ Showers — Cafeteria Q' Other fixtures --------------------------------------------- W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter---------------- Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area.........._.........sq. ft. Seepage Pit No..................... Diameter----------------_--- Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by......... ---••---•••--•..........-•---•••--••-•••--•..................... Date.................................... Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water......................... Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ --------------------------------------------- •-•-------- .... ---........ •------ •........ •.... .------ -------------- •--------------- •--------------- -----.----- ODescription of Soil.........................................................................................................................-.............................................. V ....-•-••-••••-•--••••••-•..................•••••..............• r� t�..._................------------------------------------. W ------•--•-•-•-----------••-••--••-•--------------------•--••-••••--••-•••-----••-•--••-•--•-•-••---••-............................................•-....................................... UNature of Repairs or Alterations—Answer when applicable............1-_1.5QQ___,ja.3._.s2n... .ank................................ -----------•-------------------------------•----...------------•-----...........--•-................•--•-•--•----.....4...flwdif.f.ussoms................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of T IT iE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued b the board of health. Signed Ian ; __ klA ?�1. s..- ;7 w c'r,.Z, .,,�-c r, •d,+�--------------- -•._-r -e- Date Application Approved By....... �1 ............................ ----•-. Date Application Disapproved for the following reasons----------------------------------------------------------------------------------------------------------------- ---------------------------•---------•-••-••-•--......_...•-••--.............-••-•------•--•-•••-•-•---..I....-•--•---------••••-••-----------•-•--•--••-•--•-•---•-••---•----•-•-----•--•-•-•••-•-•----- Date PermitNo........U..kln---li.K..--•--•-----------. Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .............'�.'.G?NR................O F...........15.a.01 5.�.�.�?.141 le..........................._.............. (grf#if iratr of Tuntplittnrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (Xjk by........%T_..P..MaCQ11bP_r--------------------------------------------------- ------------------------------------------------------------------------------------------------------ Off Eel-River.Roac�___©st,orvi11eal------er at -----.. . -- - - -•-_-- - ---------------- has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No.---- /_. .......... dated-............................................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE------------------�r ' ................................. . Inspector.....'....... ---------- ...................................... THE COMMONWEALTH OF MASSACHUSETTS j�� _ JCS BOARD OF HEALTH �� �� own T ................OF...........Barnst:able $ 20.00 Barnstable No.__ '..- ........_... FEE........................ Disposal Works Tnntrudion ' rrmit J P macolr.ber Permission is hereby granted-----•-•••-'-------------------------------.---••-----•--•-••••--••-•----•-••--•-••••••--•••-••••••••-••••••••......--........._........_.. to Construct ( ) or Repair ( � an Individual Sewage Disposal System atNo.•®l•f•• eI...Rimer...%4.d...95.termille.--.---------------------------------------------•---------------•---------------------------------•---.-- Street as shown on the application for Disposal Works Construction Permit No.. _"�f _ Dated............ ........................... 4 ----------------------- ..................................................... Board of Health DATE................................................................................ FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS _ TOWN OF BARNSTABLE L.QCAnQN / �1 ye_(� P—rJ SEWAGE # O VILLAGE ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. - P• M SEPTIC TANK CAPACITY L /L LEACHING FACILITY: (type) !�f l C�'t hr (size) NO. OF BEDROOMS BUILDER OR OWNER1 11� ✓J� �G�'I ilr� PERMIT DATE: S"D—F—'K- COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any weUs exist on site or within 200 feet of leaching facility) - Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 f f le chin 8 fa, c�lity) Feet Furnished by r /w TOWN OF BARNSTABLE LOCATIONG/�7/�e /( � SEWAGE VILLAGE ���'/�/ (�_ ASSESSOR'S MAP 6z LOT L INSTALLER'S NAME 6z PHONE NOi_ _ uCnyl96e� �� Lie .SEPTIC TANK CAPACITY L .LEACHING FACILITY:(tye y/Q�i��, 1-GtSDI�;�(size) NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR"OWNER DATE PERMIT ISSUED: - L/ DATE COZIPLIANCE ISSUED: VARIANCE GRANTED: Yes No j .�`r> S ° f \ w Massachusetts Department of Environmental Management '' s7• - - Office of Water Resources TYPE OR PRINT ONLY Well Completion Repoli lV�D 1. WELL LOCATIONS. GPSp{OPTiONAL)a nLATITUDE L ONGITUDE MA Address at Well Location: � i U�>` t54 /� Property Owner: 650,P6-,�5r OF Subdivision Name: Mailing Address:/ddO 1: av ,eD City/Town: ��sr 2 Ui%fE City/Town: d ,1---Zc�'LL. IM 23 G e Assessors Ma Assessors Lot#: �U NOTE: Assessors Ma and Lot# mandato if no street address available p P ry Board of Health permit obtained: Yes Not Required ❑ Permit Number ��/��' Da>lssued 2. WORK;PERFORMED ee 3.ePRQPOSED USEy, 4_,DR1LLIlNG'METHOD w _ r. �� W.� , mm. M"New Well- ❑ Abandon ❑ Domestic Irrigation ❑ Cable `tFliAuger ❑ Deepen ❑ Recondition ❑ Monitoring ❑ .Municipal ❑ Air Hammer O Direct Push ElReplace ElOther ElIndustrial ElOther ❑ Mud'f3ota ❑ Other '5. WELL LOG " oC Unconsolidated Consolidated 6. SITE SKETCH'Ose.pe►r anent tandmlirks Wth aistancesl W Permeability From;(ft) To (ft) High Low ,C7 0 m Other Rock Type , � i r� epr,r g5�p�,G I, 7.WE`LLCONSTRUCI1I04- z 8..CASING. r Total Depth Drilled 0 z From (ft) To (ft) Casing Type,and Material Size O.D. (in) Well Seal Type Date Drilling Complete 9. SCREEN ., From (ft) To (ft) Slot Size Screen-Type and Material Screen Diameter 10. FILTER PACK/GROUT/ABANDONMENT MATERIAL 11."ADDITIONAL WELL INFORMATION _ Developed? ❑ Yes. ❑ No From (ft) To (ft) Material Description-�, Purpose Fracture Enhancement? ❑ Yes ❑ No: ` f - Method j Disinfected? ❑ Yes ❑ No 12. WELL TEST'`DATA(PRODUCTION`WELLS)} 4 ' " °a' 13:'STATIC`WATER LEVEL(ALL,WELLS) Yield,� Time Pumped Drawdown to Time Recovery to Depth Below Date Method (GPM),, (hrs'a& min) (Ft. BGS) (hrs & min) (Ft. BGS) Date Measured Ground Surface (FT10 14. PERMANENT 1?UM (IF AVAILABLE) 15:°NAMEtADDRESS OF PUMP INSTALLATION COMPANY Pump Description ;Cat Via`. "" Horsepower Pump Intake Depth E: _ (ft) Nominal Pump.Capacity 1 n (gpm) 16.COMMENTS . 17. WELL DRILLERS, TA"-MEN .; This well was drilled and/or aba�r domed under my supervision, according to applicable rules �" � and regulations, and this repo ompl �e a'nd cor -ct to.the best of my knowledge. Driller: °� Supervising Driller Signature Registration #:I F. =1U yl &5zL 4)/l,'�1/r- � Date: ��� ri 1�Z- Rig Permit#:. ( L aut', I© NOTE: Well Completion Reports must be filed by the registered well driller within 30 days of well completion. I BOARD OF HEALTH COPY li 449 Rre. LV 5andwicb, MA 02-563 508(88"60) l SDID 339-6460 FAX(908)888-"M DLlEMT; Sawyer Wells LOCi70ON! Harrison ADDRESS: 7 Eel River Road E. Osterville, MA COLLECTED BY: Sawyer'Wells SAMPLE:DATE: 2/T9J2002 SAINPLU ITME: NA WATER SAMPLE TYPE. New Well DATE RIXEIVED: 2/20/2002 LAS O.D. #° 0202226 WELL S; IECS.: NA RESULTS OFANALYSOS: Parameters Units Recommended Result Method Date Analyzed Limits C;ollform bacteria 1100mi 0 0 9222 B 2120/2002 PH pH units 6.5-8.5 5.60 4500 H+ 2/20/2002 Conductance urnhos/cm 500. 166 120.1 2/20/2002 NIfrate-w mg/L 10-0 *80 300.0 2/20/2002 tltrlte-N mg/L 1.00 < 0.004 300.0 2/20/2002 Sodium mg/L 28.0 21.0 200.7 2/20/2002 Iron dngi L 0.3 < 0.1 200.7 2/20/2002 Manganese mg/L 0.05 0.017 2007 2/20/2002 COMMENTS: Low pH indicates high corrosive character stics. 5UITA FOR DRINKJNC PURPOSE'S i T MEETS PA STAI�JDARDS AMC?IS BLE i�ltfl TER EE E FOR PARAMETERS TESTED. <=less than '*•' Date Z dZ ?-greater than ConaldJ. Saari TNTC=t©o numerous to count Laboratory Director .... . - - WN TO OFBARNSTABLE s - S LOCATION SEWAGE'# _ VILLAGE L S E i Q ASSESSOR`S,MAP &.LO INSTALLER'&-NAiviE&'PHONE NO SEPTIC TANK CAPACITY dC,e�� LEACHING FACILITY: (type) `—�C C t ( r t )�E. (size) NO. OF BEDROOMS - BUILDER OR OWNER �eCCo;'� �tGi h'iL PERMITDATE: COMPLIANCE DATE: _5 ?�o/ Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility. Feet 1 Well and Leaching Facili If an wells exist � Private Water Supply g ty ( Y on site or within 200 feet of leaching facility). Feet { Edge of Wetland and Leaching Facility (If any'wetlands exist ' within 300 feet of leaching facility) Feet Furnished by tJisc i�r,s 1tia �o� ;� Q: 1'a-� No. Fee �6v THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes / PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS ✓ Zipprication for �Digoml *pztem Construction Vertnit Application for a Permit to Construct(><I Repair( )Upgrade( )Abandon( ) O Complete System ❑Individual Components Location Address or Lot No. #— E�� � f�( ". Owner's Name,Address and Tel.No. ©�tely►l\�, 4-c� G—ec,cc� 4 4v.�:� �F.vt�s�t� Assessor's MapT cel +) 3 3 �Ua 1nOVSC. l log Installer's Name,Ad ress,and Tel.No. d l61q Py\c. t ` Ck� Designer's Name,Address and Tel.No. Vtc�( ttto�4.c�c)Se. X (A►�S�(���;ovv� "'"� Type of Building: Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil LC_r. v\l� I Nature of Repairs or Alterations(Answer when applicable)�C_ Ce— ter" Ctna C usheeA a - ) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has beer issued bvAj Qgd bf Healt . Sig ,d Date Application Approved by Date Application Disapproved for the following reaso eg Permit No. anal Date Issued ;No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ✓ Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS 2pprfcation for ]h5pont *p5tem Congtruction permit Application for a Permit to Construct()<Repair( )Upgrade( )Abandon( ) ❑Complete System El Individual Components Location Address or Lot No. #-7 Eel i O Owner's Name,Address and Tel No. Os�crv�11Q , 6eocc� 4 C��VMC Assessor's Map cel ii 3 uG ' g�}• 1i:: 5C. I n 11 � c�� I G� Installer's Name,Address,and Tel.No. ���/ i��. ` TLC4 Designer's Name,Address and Tel.No. V t C k13 X Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil.. Y gy\I Nature of Repairs or Alterations(Answer when applicable) �7k,« a = )[--30X Date last inspected: Agreement: - The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by tki s,Board of Health/ /,IL�� Signeu r �' �/) Date 5 3-0 t Application Approved by �+ ! l _ �/,�i�.1/o Date Application Disapproved for the following reasons/ J - - L/ �l Permit No. `v ( .> '' Date Issued r THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of (Compliance THIS IS TO CERT FY, that the On- Sewage Di po al System Constructed( ) Repaired( )Upgraded( ) Abandoned( ),.by / r ; ;. / qn L) at 1 il__> P Z115 has been-constructed in a-cordance C If with the provisions of Title 5 and the for Disposal System Construction Permit No. --� dated �J Installer Designer The issuance of thi e t shall not be construed as a guarantee that the syste ill e ' n as desi ed/�� Date s36 Inspector / (� 519161 - Coo No. ---------�--------------Fee 1 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Diopool *pgtem Construction 3permtt Permission is hereby granted to Cron tract( CPjRe air )Upgrade( ) b and System located at f�- 1 V and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Constrdctiodmmu�st be completed within three years of the date of thpperm*t. Date: ! / / Approved by �._ .� / TOWN OFB\ARINSTABLE LOCATION �d@-f C] SEWAGE # lb I i VILLAGE �S F i��\1P-. ASSESSOR'S MAP & L01 1 No- 1® ViC-- o 4 �t� SUtS-�33-ll INSTALLER'S NAME&PHONE NO. �t;mac.\ `C'�k,,r\, Co, cJc � SEPTIC TANK CAPACITY ISDOC C-\ LEACHING FACILITY: (type) (size) NO. OF BEDROOMS f BUILDER OR OWNER e-01C-Ia le \X0 t SO n PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table'and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leachi ng facility Feet Furnished by V 1 c4 r dr 1J�� .. 4 R -4D iy J Fee-------------------- BOARD OF HEALTH TOWN OF BARNSTABLE ZppYication fforlVell Cou5tructioupermit Application is hereby made for a permit to Construct K), Alter ( ), or Repair t an individual Well at: _ L _I yea �&' — -- __ --- Location — Address Assessors Map and Parcel 3 rzoo �v���2a�k.1 N�No�o � Owner —r Address W.S'• Instal er — Driller Address Type of Building Dwelling-- --- Other - Type of Building—--- No. of Persons---.°`—/- Type of Well Orr `sum/�Jss Capacity-- ®- ' _ -- — Purpose of Well l � ���—✓ — Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Heal rivate Well Protection Regulation — The undersigned further agrees not to place the well in operation until C rtificat .o - om iance has been issued by the Board of Health. Signed -- --- date Application Application Approved By ------ —�-�1��� date Application Disapproved for the following reasons: ----- -------- -- date I Permit No.— — r — Issued-- 4 �---- date BOARD OF HEALTH TOWN OF BARNSTABLE (Certificate ®f (Compliance THIS IS TO CERTIFY, That the Individual Well Constructed X Altered ( ), or Repaired ( ) by—L -_ -__-_- -----___ - - -- --------- Installer has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation as described in the application for Well Construction Permit No.C-Q k_i&Dated LRE/42�10 THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE---- Inspector--------— - -- —---- � ,,.: -: r ,+ � ..w ,'.e- +�✓,3 r (�j " r4 $t,,.,y : n•w i�t.ri:.j,/\� �..- ) k a n,S •� P�q+•R a,-�a✓�'�.,> �.�'> r �y+� ���^/��; - ,� �------ • _ BOARD OF HEALTH u TOWN OF BARNSTABLE Applicat ion-for lVell ContructionVermit Application is hereby made for a permit to Construct K), Alter ( ), or Repair ( n individual Well at:; Location — Address Assessors Map and Parcel /Zpp 'C4a Vc/ZdEe ) h/UNC7�Cb �!J g _` J A 13.iG6 --_-- v Owner ----- Address S.:% _�� s?av�/E .Ld- Rd AVY /S/_— 1 Da4z- ------ Installer — Driller Address J Type of Building " Dwelling /2� ----- —------ Other - Type of Building ��----- No. of Persons-!'?�------- ---- Type of Well � SGIf/�?�?2Si%j��Pv�P Capacity--l�—�r��'? -- Purpose of Well� z?�1�---- -- Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Heal rivate Well Protection Regulation - The undersigned further agrees not to place the well in operation until C rtificat A omm iance has been issued by the Board of Health. Signed g — date Application Approved Bye- date Application Disapproved for the following reasons: ------------- ------ --— — -- - ,+` date Permit* _ � — ____________L— -- _-- e t No. _ Issued— �� r c� i - date } BOARD OF HEALTH TOWN OF BARNSTABLE C ertif sate ®f Compliance THIS IS TO CERTIFY, That the Individual Well Constructed (X, Altered ( ), or Repaired ( ) b L Installer has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation as described in the application for Well Construction Permit No. Dated THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE-- - Inspector--_____,---__ ___- -- ----_-_-- BOARD OF HEALTH TOWN OF BARNSTABLE Vell Cootruct ion Permit No. ---- - Fee------ ------ Permission is hereby granted t?'�'`� C - La� - — - ------------------- to ConstructP4, Alter ( ), or Repair ( ) an Individual Well at: f --------------------------- Street as shown on the application for a Well Construction Permit No.- -"� Cam-?` -1 Dated- - ----------------- Board of Health I DATE I �✓ 1 �'F" r , — 10, Proposed Well 10, 1501+ from septic system Garage House #7 Eel RiverRd. East Osterville,MA. Placement of irrigation well 12-18-2001 L.W.Sawyer Well Drilling P.O.Box 1504 Plymouth MA.02360 508-746-9465 ` DETARTR*,`r. N.MAc;.rMENY ,� 1c i >>>,��,�rt.t� R� SOURCES r� c jjZ)tTTS ELL D -I, cERTIFICATE Wit11 th=.pro Visions of fa.is.rchu5e :s General f jaws 1,f�Ater 21, Sectior► 16. f _ is iuthor,red dig or drill -well,, t III the Ct7rr�rnc�i;«LaJt'I�.of:1%1 5si clotizseit;ct IDtr rlie pe,17 ate �^ 07/01/2'001 To .06/30/2002 � � 1�rhauY fiirb��leuu rJ�li;et rr - � �' ��" _ /,ire l i(3riret r rJ If�sut�r r t,'�rr�tcr try r``'' Reg. No. 238 � � I