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0120 BERRY HOLLOW DRIVE - Health
120 Berry Hollow D,,,ve Marstons Mills p -_ - - - - A = 045 048 - i i TOWN OF BARNSTABLE h 1 LOCA-,T ON ` 6� SEWAGE # VILLA-,E "`i U'l\�VI S ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO. OF BEDROOMS BU,LDER OR OWNER PERMITDATE: 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 � Q� 4 B# Dee14 -J 4A �3 Q � 3S - Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 120 Berry Hollow Drive, Marstons Mills✓ M-45 P-48 Property Address George&Susan Quart {° Owner Owner's Name information is required for every 1005 Lakewood Lane, Bellingham WA 98229 December 7, 2016 = page. City/Town State Zip Code Date of Inspection W .ta Inspection results must be submitted on this form. Inspection forms may not be altered in any"" way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information ,t D on the computer, use only the tab 1. Inspector: key to move your cursor-do not Troy Williams use the return Name of Inspector key. Troy Williams Septic Inspections ffi Company Name 19 Hummel Drive Company Address South Dennis MA 02660 City/Town State Zip Code (508)385- 1300 S1682 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 16.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 5 December 7, 2016 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 l Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 120 Berry Hollow Drive, Marstons Mills M-45 P-48 Property Address George&Susan Quart owner Owner's Name requk dfo is every 1005 Lakewood Lane, Bellingham required for eve gam WA 98229 December 7, 2016 page:Y. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: System meets minimum standards set by Massachusetts DEP at the time of inspection only.This inspection is not a guarantee or warranty on the future working conditions of leaching, pipes, components or the future structural integrity of said components and only represents conditions found at the time of inspection only. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ® N ❑ ND (Explain below): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 7 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 120 Berry Hollow Drive, Marstons Mills M -45 P-48 Property Address George&Susan Quart Owner Owner's Name information is required for every 1005 Lakewood Lane, Bellingham WA 98229 December 7, 2016 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments y~ �M 120 Berry Hollow Drive, Marstons Mills M-45 P-48 Property Address George&Susan Quart Owner Owner's Name information is required for every 1005 Lakewood Lane, Bellingham WA 98229 December 7 2016 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well*". Method used to determine distance: "This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than %day flow t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 II Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 120 Berry Hollow Drive, Marstons Mills M-45 P-48 Property Address George&Susan Quart Owner Owner's Name information is required for every 1005 Lakewood Lane, Bellingham WA 98229 December 7, 2016 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,•.'" 120 Berry Hollow Drive, Marstons Mills M-45 P-48 Property Address George&Susan Quart Owner Owner's Name information is 1005 Lakewood Lane, Bellingham WA 98229 December 7 2016 required for every , page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 120 Berry Hollow Drive, Marstons Mills M -45 P-48 Property Address George&Susan Quart Owner Owner's Name information is required for every 1005 Lakewood Lane, Bellingham WA 98229 December 7, 2016 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ® Yes ❑ No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonal use? ® Yes ❑ No Water meter readings, if available (last 2 years usage(gpd)): 16=50,000 gals. 15=61,000 gals. Detail: Sump pump? ❑ Yes ® No Last date of occupancy: occasional use Date Commercial/Industrial Flow Conditions: Type of Establishment: N/A Design flow(based on 310 CMR 15.203): N/A Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): N/A Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: N/A t5ins-3/13 Title 5 Official Inspection form:Subsurface Sewage Disposal System-Page 7 of 17 5 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for.Voluntary Assessments 120 Berry Hollow Drive, Marstons Mills M-45 P-48 Property Address George&Susan Quart Owner Owner's Name information is required for every 1005 Lakewood Lane Bellingham WA 98229 December 7, 2016 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: N/A Date Other(describe below): NIA General Information Pumping Records: Source of information: Last pumped in 2013 per info from BOH. Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): 15ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage.Disposal System Form - Not for Voluntary Assessments 120 Berry Hollow Drive, Marstons Mills M-45 P-48 Property Address George&Susan Quart Owner Owner's Name information is required for every 1005 Lakewood Lane, Bellingham WA 98229 December 7, 2016 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: Tank, d-box and leaching were installed on 9/30/96 per compliance. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1811+ feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): - Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Lines were found clear at the time of inspection. Septic Tank(locate on site plan): Depth below grade: 2'with riser to 6" feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 6'X10.5'X6' 1500 gallon Sludge depth: 4" t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments .' 120 Berry Hollow Drive, Marstons Mills M-45 P-48 Property Address George&Susan Quart Owner Owner's Name information is 1005 Lakewood Lane Bellingham WA 98229 December 7 2016 required for every � , page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 21811 Scum thickness none 611 Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 14" How were dimensions determined? probe/measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pvc inlet and outlet tees were found present and in working order. No evidence of leakage or damage was found. Tank was not in need of pumping at this time. Grease Trap(locate on site plan): Depth below grade: N/A feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: N/A Scum thickness N/A Distance from top of scum to top of outlet tee or baffle N/A Distance from bottom of scum to bottom of outlet tee or baffle N/A Date of last pumping: N/ADate t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 120 Berry Hollow Drive, Marstons Mills M -45 P-48 Property Address George&Susan Quart Owner Owner's Name information is required for every 1005 Lakewood Lane, Bellingham WA 98229 December 7, 2016 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: N/A Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: N/A Capacity: N/A gallons Design Flow: N/A gallons per day Alarm present: ❑ Yes ❑ No Alarm level: N/A Alarm in working order: ❑ Yes ❑ No Date of last pumping: N/A Date Comments(condition of alarm and float switches, etc.): N/A " Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 120 Berry Hollow Drive, Marstons Mills M-45 P-48 Property Address George &Susan Quart Owner Owner's Name information is required for every 1005 Lakewood Lane, Bellingham WA 98229 December 7, 2016 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert level 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.): D-box was found level and in working order. No evidence of solid carry-over or backup in the past was found at the time of inspection. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): N/A * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 120 Berry Hollow Drive, Marstons Mills M-45 P-48 Property Address George&Susan Quart Owner Owner's Name information is 05 Lakewood Lane, Bellingham WA 98229 December 7 2016 required for every 10 — page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 3 flowdiffusers with stone ❑ leaching galleries number: 32'X 12'X 2' ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Soil was sandy. Chambers were dry at the time of inspection. Checked stone and found dry and clean. No evidence of hydraulic failure or problems in the past were found at the time of inspection. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration N/A Depth—top of liiquid to inlet invert N/A Depth of solids layer N/A Depth of scum layer N/A Dimensions of cesspool N/A Materials of construction N/A Indication of groundwater inflow ❑ Yes ❑ No t5ins-3/13 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments wM ,.•�''y 120 Berry Hollow Drive, Marstons Mills M-45 P-48 Property Address George&Susan Quart Owner Owner's Name information is 1005 Lakewood Lane Bellingham WA 98229 December 7 2016 required for every , page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): N/A Privy(locate on site plan): Materials of construction: N/A Dimensions N/A Depth of solids N/A Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): N/A t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 120 Berry Hollow Drive, Marstons Mills M-45 P-48 Property Address George&Susan Quart Owner Owner's Name information is 1005 Lakewood Lane, Bellingham WA 98229 December 7, 2016 required for every g page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately �,.►a�'✓'i � �A/ I I ' � ' I � I I nwvW �� y � A � - ►I ' i L ; �� ,� L z2 .y f 3 - ,Z3.y ' 3 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �M ,.•''r 120 Berry Hollow Drive, Marstons Mills M -45 P-48 Property Address George & Susan Quart Owner Owner's Name information is g required for every 1005 Lakewood Lane, Bellingham WA 98229 December 7, 2016 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) . Site Exam: ® Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 20'+ feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 12/6/96 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: USGS groundwater map 25.0'to water. You must describe how you established the high ground water elevation: Test hole recorded on plan showed no water found at 10.0'. Plan design shows bottom of leaching to be 18.0' above groundwater. System installed to plan. Bottom of leaching at 6.5'was found not to be located in the high groundwater elevation at the time of inspection. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 120 Berry Hollow Drive, Marstons Mills M-45 P-48 Property Address George&Susan Quart Owner Owners Name information is required for every 1005 Lakewood Lane, Bellingham WA 98229 December 7, 2016 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 `OWN OFBARNSTABLE LOCIiTION %' SEWAGE # 1 S t�VILLAGE ='' fi ASSESSOR'S MAP & LOTOIL/6"-64) INSTALLER'S NAME&PHONE NO. fA Q12 Vt( 1-10 SEPTIC TANK CAPACITY S oo ,3-1 LEACHING FACILITY: (type) 3 ( 16 (size) NO.OF BEDROOMS BUILDER OR OWNER OC 4 f'S '• /�J D tC'`� PERMIT DATE: 7 COMPLIANCE• DATE: Separation Distance Between the: 'Maximum Adjusted Groundwater Table and Bottom of Leaching Facility. f 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 L G 1( X p N ^ �C A N. i; - ASSESSORS MAP NO: 9 / PARCELN% -7 Fmc THE COMMONWEALTH OF MASSACHUSETTS y BOAR® OF HEALTH TOWN OF BARNSTABLE 7 .��.� �r�tt>a t �ur �t,���t,�tti ,ark C�>agt��r�tr#tnn eruttf Application is hereby made for a Permit to Construct PP y t ( ) o Repair ( ) an Individual Sewage Disposal S A t: �^ Location-Address or Lot o. --------------•---..... -c�G3 ! ,� ------------------ -------- / i!! �.5..... .................................. own i .' �&ress ress a •--•-----••------- -'� 10 `� ------------ ................. '`�lolInstaller UType of Building Size Lot__`� ..-�r..�0._..Sq. feet �. Dwelling— No. of Bedrooms.........-----------------------------------Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ---------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( ) d Other fixtures .. W Design Flow.....................................gallons per person per day. Total daily, flow..........3..3P-_------:--......gallons. WSeptic Tank—Liquid capacitv/SCdgallons Length---YP--___ Width---S Diameter_... Depth _�.." x Disposal Trench—No. -------- -------- Width...../ ....... Total Length----- Total leaching area------_57'KP.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..------= D...�- ---- -------------- Date------- �. _..__:. Test Pit No. 1..L.2.-minutes per inch Depth of Test Pit------/ ., Depth to ground water........................ Gi. Test Pit No. 2...L.2..minutes per inch Depth of Test Pit--.-.?®__...... Depth to ground water........ I F/ Soil 0 ../7�t9 ,�-- '� -5..... -^t`t ? .Z 3._� ;._.... O Dgscri tion of x S.Ei?�!�1�_1.�� }v --- ...r.�.r°'- nor 1�Z c�"_. ` � . 'v -- ' : �"G� U Nature of Repairs or Alterations— nswer when applicable.------ -•-•---•-••.................•--•---......-•----......-•----..._....__.........----------....-----••---•-----•-••------------••---•-•----------•-•-----.......-------•--------••-------•-.....----.---•-- Agreement: The undersigned agrees to install the afore cribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environ e tal Code—The undersigned further agrees not to place the system in operation until a Certificate of Complianc been issue by the oard of health. Signed ----- ------- ------..:. ..... .---- � - �.... ................. Application.Approved .. .. .. ....... �.- ��`�..1W_ ---- ---- ---------- Dace Application.Disapproved for the following reasons- --------------------------- --------------------------------------------------------------------------------------------------- ----------------------------------------- ---------......----------------------------- ----------....._......-------------------------_..._------ 1 Dare Permit No. ..... Issued.... Issued ------�. Dace �. THE COMMONWEALTH OF MASSACHUSETTS ' i BOARD OF HEALTH �r TOWN OF BARNSTABL 5;E .� �ltrtttiu�t° furiuutti Turku*C�u�turnr#iunrrutt A t Application is hereby made for a Permit to Construct ( /) or Repair ( ) an,Individual Sewage Disposal System at: Location-Address or Lot No. -- Owner Address ,Wa ........................ . f !zn — ------ t r✓�"/� J'----------- ---------w Installer A dress U Type of Building Size Lot___-99 17"___Sq. feet Dwelling— No. of Bedrooms-__._.__•__________________________-_--____Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ____________________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) 04 Other fixtures . ----------------------------------------•----••••-•-•-------- W Design Flow...................��_�..............gallons per person per day. Total dail flow.............:5_`. Fa___________,__-___gallons. 9 Septic Tank—Liquid capacity X5.QAallons Length___-/0.'_ Width---- ..... Diameter--_"�-- De th_��"__ _A_" P Disposal Trench—No. ......../_....... Width......1�----- Total Length------ Total leaching area......."V"!£A-b.sq. ft. 3 Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. z Other Distribution box ( ' ) Dosing tank ( ) ��jj// - '~ Percolation Test Results Performed by-------_ _____._.11.406______________ Date._..____g� -_%� � ..� / - ---------- Test Pit No. I...4__Z._minutes per inch Depth of Test Pit-------I.1�__-___ Depth to ground water......._..�s ,Test Pit No. 2___�_Z._minutesper inch Depth of Test Pit....../0..�_. Depth to ground water......... Description of Soil._ ( _�°"_. '!` nr©' ._ �^?-:S` - 3 S'�a /.. - �--�--- --- ---------- - �--- ��-�-------------- ........ fit•-----...__.. U tylL ,G:r Qs ,... ------ ---r --�/ .__c '_ 'l.�r. / �9 '!-1 ,-9" -G-� U Nature of Repairs or Alterations—t�nswer when applicable._,____/ ' d �%! 5> -' •6r/.�?��� - aM' .................................................................. Agreement: ' The undersigned�agg ees to install the afore,e cribed Individual Sewage Disposal System in accordance with the provisions-of'TITLE 5 of the State Environ e tal Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has�been issued by the.board of health. 4 Signed ---- ------ ----------- _ _..... .......... ----�...3�.. Application,Approved 135C.----------. _.... . ' `-'., :40-;,'/�--T---'�---� Da[e Application Disapproved for the following reasons: ------------------------------------------------------- ----------„-------------------------- -------------,.-...... ------- ---------- -- ---------------------------------------------------------------------- ------------,--------- -------- f Due Permit No. ----- A.-- :. ----- ..— Issued ......: ----- } Dace f THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARR�NSTABLE Tertifi ate of V�IImplidnve THIS IS T9,.GERTIFY, That the Individual Sewage Disposal System constructed ( v ) or Repaired ( ) by - e.',/ 1Z -�� .... ;+ rp �/ ' - -- Inar.Jler at ----------------------------- ' ' has been installed in accordance with the provisions of TITI. 5 of The State Environmental Code as described ri in p bd e the application for Disposal Works Construction Permit No. .. o ':7 dated THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE TH�ATTHE SYSTEM WILL FUNCTION SATISFACTORY. DATE.............-------------.! _, (ti.---Y.7....._................................... Inspector ........ . THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH , ?" TOWN OF BARNSTABLE / No........................ FEE/-- Ropuuttl Workii Tunitrur#iun rrrmit Permission ii hereby granted............ /�� >/ i t ............................................ to Constru �/ ) or Rye air ( ) an Indivi ual Sewage Dios t stem . ',.- treet as shown on the application for Disposal Works Construction Per 't /, -Z''ted.._.1-7.- DATE .. Board of Health "_._...._ -------•--------•--- FORM 36508 HOBBS Q WARREN,INC..PUBLISHERS 1 r. 517Z' pLs3.v Al LOCATION SCALE DATE Two.,/? If t PLAN REFERENCE , BEOWC, .47.`•,.. .7` . \ � oc des r "�'�("'.•.., •• O •p \ mil` E;'W ARD ti S$. � "—i � � � o• 3�`c.�� ` ` Kftjrty� 100 Z107- 76, LOT '7 , , Go got do , �'y � � ,�� o •; .; _ a„ � � of ��, � ,� � �2 vo /Vozza J.� �';D2WEoolw�l IN4-ZC. ^� ��� �� / // 1 1 ` f `�l• I ° � v 6 dk TOP OF FOUNDATION CONCRETE COVERS 4 CAST.IRON 9,r . OR SCHEDULE 40 4°SCHEDULE 40 P.V.C. (ONLY) 9.' MIN . P.V.C. PIPE MIN. 36" MAX. PIPE-MIN.� LEACHING TRENCH (....REQUIRED)PITCH I/4��PER.FT. PITCH 1/4� PER.FT. � 1 . y I/8"-i/2�� WASHEDnSTONE z�z v'. INVERT n`�J r.1 n�n m�' rr'-3 i n ;,o EL 72;35, INVERT DIST. INVERT =n AV- SEPTIC TANK EL 7/„1�Z. BOX EL��` 8 3/411-11/2°WASHED STONE :. INVERT ESQ GAL.. INVERT EL.Ze:�.7.. INVERT EL.7o:e..� EL�9.7z LOWDIFFUSORS EL 9 ....... •,,. 6"CRUSHED STONE /. � � REQ. 6o GV6�Z ZJ I Z4/ 3z/ r PROFI LE OF GROUND WATER TABLE SOIL LO/G SEWAGE DISPOSAL SYSTEM TYPICAL CROSS SECTION NO SCALE LEACHING TRENCH . NO SCALE TEST HOLE I TEST HOLE 2 ELEV. .73:6� .. . . ELEV. 7,`S?4. ... DESIGN DATA 1/8'=1&' } 3 9. MIN. WASHED 36"MAX. NUMBER OF BEDROOMS STONE 330\ � TOTAL ESTIMATED FLOW . . . GALLONS/DAY 3S EG.70•b$ 35 \ :z.7Z,o8 BOTTOM LEACHING AREA . `38�0 n \ \) C/(,p, ;lv S0QMD // ";' C' (pA+ry :.. .... SQ.FT./TRENCH o 0 �� �� Sao wGRAVgL 8r3,a)42.0-�/7Z'o Go" G i �rrA, 66,e.0 �Z.'�/,00 SIDE LEACHING AREA . . . . ... . . . ... . SQ.FT./TRENCH//3o.Z „ f� 3/4-I I/2 WASHED .. f'&'°'/ GARBAGE DISPOSAL .NaNe.(50% AREA INCREASE) STONE .-tee or- Rih 6 /EFZ. TOTAL LEACHING AREA SO.FT.. ..��� / �z. G s:6 o M eD, "-11 over/4 i PERCOLATION RATE LESS Tf,!Rr/77No h!y/PER. INCH /Z LEACHING AREA PER PERCOLATION RATE4��`7. SQ.FT�6;PD. GROUND WATER TABLE /�" C�z G�7,Go /70'/ �Z•GS.Oo APPROVED .. . . . . . . . . . . . .. BOARD OF HEALTH .M?. ..WATER ENCOUNTERED DATE ... . . .. . . . . . . . . . �ZK OF AGENT OR INSPECTOR `P s , WITNESSED BY ED�YARD 7.. L G' �rz Go .� �. . . . �. . . . �. . . .��. . . . . . . .. BOARD OF HEALTH . . . . . . . r . . . . . . eJ N � itEL .S �r$a/✓ • 14L-G /�S.• ENGINEER / k l7�Vu� ry � 100 ��lN,�lzp L�=ICCuG'�i•�.RG�S. ��-rzsrv!✓S' �`i/u s , . r ; �/a�R1GISTI PETITIONER �- ' - ' » Title 5.- Draft Pfinted September 20 1993 Appendix 4 Page 2 .. �- �^ Oamp HoleNumnber------. Om1e:'/���'�^f � � Thno: Weather .............................................. Location (identify on site plan) ........:.............................................................................................................................................................................. Land Une ------------------ Slope (Y6> ------ Surface Stones ---------------------------. � " . � �w�wp"= � Londformm � Position on landscape (sketch on the back) -------------..................................... Distances from: ' OponVVatarBody ------ feet Droinogevvay --_-- feet Poosido \NetAree ------. feet PropemmUne -.----- feet Drinking Water Well ____-. feet Other DEEP OBSERVATION HOLE LOG Depth from Surface Soil Horizon Soil Texture Soil Color Soil Mottling Other (Inches) (USDA) (Mungelf) (Structure, Stones, Boulders, Consistency, % Gravel) 16 MO 1171� cog � � � � Bedrock: ----.---- Debth to Groundwater: Standing Water in th e Hole: ................... Weeping fnmnm Pit Face: .................. Estimated Seasonal High Ground Water: - � ' sir f>t�a - 7 Al LOCATION SCALE . - DATE PLAN 12EFERENCE , f3E7/ Gq, O x E. I y K£LLE to d - ^\ ` °6 \ No. co i \ \� AQ got zr r s P lo tiX// 6 >r 74C[;co,&5 /`1 D.r?✓M— ��T �-- EL..?Z.oo Sf� "T Z 0.Ac:* .3 .5/71 '7—S TOP OF FOUNDATION CONCRETE COVERS 4"CAST.IRON 9'� �! ' .,,.. err-�i.,,,,• OR SCHEDULE 40 , 4"SCHEDULE 40 P.V.C. (ONLY) 9'MIN . 36" MAX. P.V.C. PIPE MIN. PIPE-MIN. PITCH 1/4"PER.FT. PITCH 1/4"PER.FT. } LEACHING TRENCH (....REQUIRED) ( y • 1/8"- I/2' WASHEDnSTONE Z•,Va • �— 4- o'. INVERT L—J �' n`iJ �1ii�" n` V n /Z� EL..7A,35 INVERT DIST. INVERT - SEPTIC TANK o 8 3/4"-t l/2"WASHED STONE /Z'� ,;. INVERT EL.Z4"� BOX EL7...M. L.GA . INVERT EL..Z.�72 �' -�o,� INVERT FLOW DIFFUSORS INVERT • EL�9:7Z RUSHED STONE ( .3 R EQ. C o, 37,1 -; 0" PROFILE OF r .•e,;,, GROUND WATER TABLE / SEWAGE DISPOSAL SYSTEM TYPICAL CROSS SECTION SOIL LOG LEACHING TRENCH DATE Ax?,/� � 95 TIME ./. :/-r� NO SCALE NO SCALE TEST HOLE I TEST HOLE 2 , �3:60 .. . . ELEV. -�t?�. ELEV. . ... DESIGN DATA 9 MIN. WASHED 36'MAX. L -o%2,Z Cyr , ' NUMBER OF BEDROOMS �.. . . . . . . . . . .. STONE { /y TOTAL ESTIMATED FLOW . . . 330 GALLONS/DAY EG.70.6$ 3,S rr ND �� r,<! �Z'og BOTTOM LEACHING AREA `3 0... SQ.FT./TRENCH/2 Z �/2 Y C,P.D rr so crzRvYt o 0 Ez,6y,6 o f 8�o�c Z.o Goer cz.,rD, 7/,00 SIDE LEACHING AREA . . . . ... . . ... SQ.FT./TRENCH/C�`Z� 3/4"-II/2°WASHED /Zv cz,6B.6o - .r �' �'�'!�� � GARBAGE DISPOSAL /✓Dn/ .(50% AREA INCREASE) STONE 84 sew zu%i t o tL CZ� � D... ..: SOFT. fCa sip of 61z.9�/C$Z Mom. TOTAL LEACHING AREA LESS Th!AT!TtvO HiN , PERCOLATION RATE /PER.INCH /L colas�C' s,qN� %Clzsrvtz LEACHING AREA PER PERCOLATION RATE41,447. SO.FTl6;�D- _ �� �Z-Zoo APPROVED BOARD OF HEALTH5, .. . . . . . . . . . . . .. GROUND WATER TABLE /Zo GsL. 63,Go /Zo .N'R. ..WATER ENCOUNTERED _ DATE ... . . .. . . . . . . . . . . . .. .. . . . . . . . . . AGENT OR INSPECTOR 3ti��`� OFs WITH ESSED BY : L� ��Z2 BOARD OF HEALTH S7Gs'T$O/f y6)LL / s.. ENGINEERl1GGtl !7/LIt/u� `28100 G—�1N,9? G�:/CG-? G � ✓�P.L,S. /t,� A/s- /`//GZs �SEraio N TAB PETITIONER �,AC�j(J�S MO/Z4N/- - � ' 3 0,= 3 � Rile 5: Draft hinted September 20 1993 Annendir 4 Page 2 ° . . . .. .. �� .OoepHo|eNurnber------ '/��'�^[/rj_� Deta� Tlnna:�~��'5 Weather ............................................. Location (identify onsite plan) ---------------------_-----------_------------------------ | Land Use ......................................................... Slope M ------ Surface Stones ---------------------------. -g-_--n Landfonn � Position onlandscape (sketch on the back) -------------------------------------------------- Distannemfnom; � OpenWaterBody -_--'- feet Drainagavvay ----'- feat Possible Wet Area ................... feet Property Line ----- feet � Drinking Water Well _____' feet Othor ____-_______- DEEP OBSERVATION HOLE LOG � Depth from Surface Soil Horizon Soil Texture Soil Color Soil Mottling Other (Inches) (USM (Munsell) (Structure, Stones. Boulders, Consistency, % Gravel) 13 Dedth t6 Groundwater: Standing Water in the Hole: .................. Weeping from Pit Face: .................. Estimated Seasonal High � � � GnoundVVater: -----' � �� . 'e Oct-01-96 11 :36A Jacques N_ Morin 1-508-771-2116 P .05 AUG 04 '95 09:iOAM BARN CTY COMMRS 5083624136 P.6 Bottle. Number: 819401 Date : 06/04/95 BARNSTABLE COUNTY HEALTH AND ENVIRONMENTAL DEPARTMENT- , 6UPER101%OOURT HOUSE BARNSTABLE, MASSACHUBEM 02630 A 5 PHONE,392.2511 LAS 337 Client: MEEHAN, EDWARD Collector: THOMAS BOURNE Mailing MEEHAN WELL DRILLING Affiliation: LAB DIRECTOR - Address : 338 ROUTE 130 UNIT 1 SANDWICH MA 02563 Type of Supply: Private well. Telephone : Well DeDth: 75 FT Sample Location: 78 BERRY HOLLOW ROAD Date of Collection: 07/31/95 Towel: MARSTONS MILLS Date of Analysis : 08/01/95 -•c�r�csa�c����C�7S7CRn========aan9�a�1�a T.�s��S�c�.2x a nc�.::=.T.G^DS�S�-��G������_���-!�� PARAMETER SAMPLE RESULT RECOMMENDED LIMITS Total Coliform Bacteria/100mL• 0 0 PH 6 . 2 Conductivity (micromhos/cm) 80 500 Iron (ppm) 0. 3 Nitrate-Nitrogen (ppm) < 0 . 1 10 .0 sodium (ppm) _ 2"0 copper (ppm) —.. 1.3 EASED ON THE ANALYSES PERFORMED, THE FOLLOWING ADVISORIES ARE GIVEN: • Water sample meets the recommended limits for drinking water of all above. tested parameters . Thomas F. Bourne, Laboratory Director Oct-01-96 11 :36A Jacques N _ Morin 1-508-771 -2116 P _06 AUG 04 195 09:OBRM ERRN CTY UUlr MKb WtUbd41-1b r.c Barnstable County Health and Environment 1 Laboratory Super r Court House, Route 6� P.O. Box 427 Barnstable, MA 02630 (508Y3t -2511 ext . 337 Volatile Organic Analysis Analytical Method: 502 . 2 Collection Date: 07/31/95 Date Received: 08/01/95 Analysis Date: 08/02/95 Client: - MEEHAN WELL DRILLING Mailing MEEHAN WELL DRILLING Sample Location: 78 Address,. 338 ROUTE 130 UNIT 1 BERRY HOLLOW ROAD SANDWICH MA 02563 MARSTONS MILLS Sample ID: 819402 Laboratory ID: 819402 Sample Description: PRIVATE WELL Compound Amount Detected. (ug/L) Detection Limit (ug/L) Benzene BRL 0. 5 Bromobenzene BRL 0 . 5 Bromochloromethane BRL 0 . 5 Bromodichloromethans BRL 0 . 5 Bromoform BRL 0 . 5 Bromomethane BRL 0.5 n--Butylbenzene BRL .0 .5 sec-Butylbenzene BRL 0 .5 tert-Butylbenzene BRL 0 . 5 Carbon tetrachloride BRL 0. 5 Chlorobenzene BRL 0 .5 Chloroethans BRL 0 . 5 Chloroform 15 0.5 Chloromethane BRL 0 . 5 2-Chlorotoluene BRL 0. 5 4-Chlorotoluene BRL - Dibromochlor7methane BRL 0. 5 1 , 2-Dibromo-3-chloropropane BRL 0 . 5 1, 2-Dibromoethane BRL 0. 5 Dibromomethane BRL 0 . 5 1 ,2-Dichlorobenzone BRL 0. 5 1 , 3-Dichlorobenzene BRL 0.5 1 , 4-Dichlarobenzene BRL 0.5 Dichl-orodifluoromethane BRL 0 .5 1 ,1-Dichloroethane BRL 0.5 1 ,2-Dichloroethan6 BRL 0 . 5 1, 1-Dichloroethene BRL 0 . 5 cis-1 , 2-Dichloroethene BRL . - 0 . 5 trans-1 ,2-Dichloroethene BR 0 . 5 1 , 2-Dichloropropane Bill, 0. 5 1 , 3-Dichloropropane BRL 0.5 2 , 2-Dichloropropane BRL 0. 5 1 , 1-D-ichloroprop®ne BRL 0. 5 cis-1 , 3-Dichloropropene BRL 0 . 5 trans-1, 3-Dichloropropens ARL o. 5 Ettylbenzene BRL 0. 5 Hexachlorobutadiene BRL 0.5 Isopropylbenzene BRL 0 .5 4--Isopropyltoluene BRL 0. 5 BRL: Below Reporting Limit Oct-01-96 11 :36A Jacques N. Morin 1 -508-771-2116 P .07 AUG 04 '95 09:09AM BARN CTY COMMRS 5083624136 P.3 pagb 2 - Sample ID: 819402 Laboratory ID: 819402 Compound Amount Detected WOW Detection Limit (ug/L) Methylene chloride BRL Naphthalene BRL 0. 5 Pr opylbenzene BRL 0 .5 Styrene BILL 0. 5 1 , 1 , 1 , 2-Tetrachloroethane BRL 0 . 5 1, 14, 2-Tetrachl.oroethane BRL 0 . 5 Tetrachloroethene BRL 0 . 5 Toluene BRL . 0 . 5 1,2,3-TrichlorobenBene BRL 0. 5 1 , 2 , 4-Trichlorobenzene BRL 0 . 5 1, 1,1-Trichloroethane BRL 0. 5 1 ,1 , 2-Trichloroothane BRL 0 . 5 Trichloroethene BR.L - 0 . 5 Triahlorof'luoromethane BR 0 . 5 1,2, 3-Trichloropropane BRL 0..5 1, 2, 4-Trimethylbanzene BRL 0 .5 1 , 3,5-Trimethylbenzene 8RL 0 . 5 Vinyl. chloride BRL 0. 5 Total Xylenee BAL 0. 5 a Mi Below Reporting Limit Thomas F. Bourne, Laboratory Director r I No.lk'--q- ------- - Fee----OL�------- BOARD OF HEALTH TOWN OF BARNSTABLE Application-*rVe[r Cootructionpermit Application is •er made for a permit to Construct ( ), Alter ( ), or Repair ( �nindividual Well at: Location — Addres Assessors Map and Parcel -_1a Owner Address_ --'3 IV � Installer — Driller _ — Address Type of Building Dwelling--------------------------------------------------------- Other - Type of Building----------------------------- No. of Persons---------------------------—___—_--___-___ Type of Well---q ---- - ---- - ------- Capacity-------------------- -- -- - - -- Purpose of Well 1 Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation - The undersigned further agrees not to place the well in operation until a Certificate .of Compliance has been issued by the Board of Health. Signed ---------------- ----------------------- �date•� Application Approved By ^-'1 ¢— �- - ---Z= -L-^-- .5 V �.J — _--- —--—— date Application Disapproved for the following reasons:—_—______________—___-___________-_____________—_______—__—___—________ - ------- ---------------------------- date Permit No. ------- Issued--- -- - - --- ----------- -------------- date BOARD OF HEALTH TOWN OF BARNSTABLE (Certifirate Of (Compliance THIS T9 CERTIFY, That the Individual Well Constructed ( ), Altered ( ), or Repaired ( y� -- ------------------------------------------------------------------------------------------ / Installer at- - L p w -ls/_ r ,--__ --- ----==--/h%L7------------------------ ---- --- ---- --- 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. 14?51 nS-6---Dated THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE----------------——---- ---- Inspector---------------------------------------—--- ----------- -,•'"'�....,..0.`yr".-+ti14:�Ki^.••"hfJ�`: .�f -_ �.��.,y�_�� r l���ytij"`Y`'.yvX'�'n+�S4r. ..7,. , ..L��. �- _i � `..j a tT+ `•rsrr�tT'�•`.' .-'Y�7 7r�}vr�S t�"� �yr+�,,� v�'',`�1'"71.�e l�F'+-��'�'7'�KZ"( -.{.mil}*-�+�`✓'�'�� Oki <6 No d _ Fee---- - BOARD OF HEALTH , TOWN OF ' BARNSTABLE Applicat ion Ar Veil Con5tructionPermit Application is herebyi made for a permit to Construct ( ), Alter ( ), or Repair ( Safi individual Well at: --------- ---- ------- Location — Address Assessors Ma and Parcel P ----l q-r-5 -'�-C /�1�1------- -- Owner Address �`-_- Installer — Driller Address Type of Building iDwelling------------------------------------------------------------- Other - Type of Building ------ No. of Persons----------------------------------------------- I Type of Well- - -`-- - - -------- - Capacity------------------------ -- - —- - Purpose of Well------ Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The . Town of Barnstable Board of Health Private Well Protection Regulation - The undersigned further agrees not to place the well in operation until a Certificate .of Compliance has been issued by the Board of Health. -Signed .?T '��,� -�_--p1 -��=---------- ----------------- date 4_ Application Approved By—.... - �' -� -- -- ---7'a— - 1 S — )--- date Application Disapproved for the following reasons: • -------------- --------- -- - ----- - - --- - --------------- - - -- - ---- ---- date Permit No. -- -= - ----- — -- Issued------------ ----------------- ---_---- - f BOARD OF HEALTH TOWN OF BARNSTABLE Certificate Of' Compliance - THIS IS_,T CERTIFY, T t the Individual Well Constructed ( ), Altered( ), or Repaired ( y� �� --------------------------------------------------------------------------------------- Installer l,� �.}^ at------- ! O-- --�-- -r ---------- $ ------------------------------------------------ -------------------- 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. � --'5�5----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 t TOWN OF BARNSTABLE I Yell CongtructiouPerntit No. Permission is hereby granted- — to Construct Alter ( ), or Repair ( =21:nclividual Well at: No. ------ -- Street as shown on the application for a Well Construction Permit No. Dated--- = -' ��- ----------------------------------- ri s 3 ` - — - -------------------------------------------- ------ Board of Health. DATE—-- 7=- - .Si ram- PG,q� LOCATION SCALE , DATE 'T PLAN REFERENCE ,B�,vG ..47.-.' 77... . A SSE3So e6 M S !aA1?LBZ, 48 0 � h i "o Air v l ^ ^� q 8� nA.PI u S 0 too ./ nS op 6 0 Sou"��. $ .� `'� H r �LLEY 26100 i SAL L9��� V / APPLICATION FOR PERCOLATION TEST AND OBSERVATION PITS V LOCATION 100 /3Es70� / ICU tom/ ./�/ NO. P- BS4� VILLAGE DATE 7 z f __ APPLICANT oes FEE ADDRESS_ / ,,A//•-5 �� TELEPHONE NO. (Non-refundable ENGINEER S7 ?"So�/ yfYLL 2,5, TELEPHONE NO. 4Z8-4347 DATE SCHEDULED__ (Applicant' s signature) . A SESOSMAP.6.z LOT . . . . . . . . . . . . . SOIL LOG SUB-DIVISION NAME DATE S ��j'.S TIME EXPANSION AREA: YES XNO Sio,c✓ �/.AGC, 25, ENGINEER Join vgrrr? TOWN WATER PRIVATE WELL F6n/n72, .1�92r2y nn��r�'�'•CE BOARD OFE✓tEALTH C 4'✓ut^S /'Jo/Z/,t/ EXCAVATOR SKETCH: (Street name,etc. ,dimensions of lot, exact location of test holes and percolation tests, locate wetlands in proximity to test holes ) NOTES : / o 0 N LoT 78 �3 -70 o_ V PERCOLATION RATE: TEST HOLE NO: / ELEVATION: TEST HOLE NO: .2 ELEVATION: O-!o„ 1 O //oiE'�z C7-� " 1 2 �% 13//ORi2��'�.✓� 2 %:' ;%%i; 3 s/cC,z -�'•�I.Np y.�Q.�J.� M - /aY� 6/� .i / A3 YR 6/G /• C h�a�.z�.Cor�.•,YSs�iv.� -• C'i1p.,'�z - .Co.�»Y.I<.wv r✓�l�-{'A�•<G y8 1-4C�6as�✓ac�/o y�?S/(� �f'8 4 _ .'o: «' ✓o Yr? 6"/6 . 5 io�.Z 71 9 ° t .C3 rJ60 Comae r,4,t'n.va w/ g /a Y,� T/B / 10 e,• _ �✓sc /oY,C' 71,g 10 . 11 / 1 12 12 13 13 14 -14 15 15 16 16 SUITABLE FOR- SUB-SURFACE SEWAGE: LEACHING FIELD ✓LEACHING PITS LEACHING TRENCHES UNSUITABLE FOR SUB-SURFACE SEWAGE. REASONS: NOTE: ENGINEERING PLANS MUST SHOW NUMBER .ASSIGNED ON PERC TEST APPLICATION ORIGINAL: COMPLETED IN ENTIRETY BY P , E , AND RETURNED TO BOARD OF HEALTH COPY: RETAINED BY APPLICANT