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0021 PEBBLE PATH - Health
21 Pebble P Ol�Mar'stons Mills `V - A=046-050-427 - No..........`r .... i .� THE COMMONWEALTH OF MASSACHUSETTS P BOARD OF HEALTH _. . ... TOWN......OF........BARNSTABLE - . ......... Appliratiuu -fur 4:31,spuual Worho Tomitrurtiun Prrutit Application is hereby made for a Permit to Construct (X ) or Repair ( } an Individual Sewage Disposal System at: Pebble Path Lot 427 -------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------- Location-Address or Lot No. f' P.At S A.----CrsAP------------------ ...60 -�t---..?V.7..... ....................................... Owner Address ------------------------- a....I�'-N j ................................. ........................SA.M.F. Installer Address d Type of Building Size--Lot -----------------------Sq. feet U Dwelling—No. of Bedrooms_________________3........................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ____________________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) a' Other fixtures ------___-------------------------- W Design Flow ...........................gallons per-fw*serl per day. Total daily flow.._..--------._....---.._...---------------gallons. WSeptic Tank—Liquid capacity 100 Ogallons Length$�_-_6...... Width._4_'_7.10 5iameter__-___--.-.____ Depth.- .�.- xDisposal Trench—No. .................... Width.................... Total Length.................... Total leaching area.--._-_-_.__.--_.---sq. ft. Seepage Pit No......I............ Diameter........10....... Depth below inlet.....6............. Total leaching area------2.6 Z....sq. ft. ' Z Other Distribution box (X ) Dosing tank ( ) aPercolation Test Results Performed by Cape_...God...Survey...Coris_ultantVate...1�1d.9_._.__B....... Test Pit No. 1 C 2__-___--minutes per inch Depth of "Pest Pit...9.'------------ Depth to ground watenXIOn-e---_--_---- w Test Pit No. 2----------------minutes per inch Depth of Test Pit____________________ Depth to ground water__.--.----_---.--__----. 19 ------•--•------------ .........................---.................---------------------------------...................................................... 0 Description of Soil_----0-0_ 5---humus.,....0_ 5-3...0_ - C2 ___s_a d_,.... ...0.-.6..-0...g eve-� _ th-------------- cxj ------------------------------ sandt....6._D-9___Q...sand " - W ------------------------------------------- ------- �.---------- V Nature of Repairs or Alterations—Answer when applicable._---------------------_-____------___-_-_._. . -_---RENUaCICK-... � .__--.-_. ..-•--•-•---------------------•-•---------------...._---------------•---••--• ............................................. •-------•---------- ----- �- -----•--B.-• ---- -- -�- ------- Agreement: C P C The undersigned agrees to install the aforedescribed Individual Sewage Disposal ip to acc with the provisions of Article XI of the State Sanitary Code— The undersigned further agrees ° G/ ex- � tem in operation until a Certificate of Compliance has been issued by the board of health. NAL E Sied----- ---- ---------• ...................----------------------------._......... Da A lication Approved B ,,l2 �:. Date Application Disapproved for the following reasons:........... -•---•----•-.._.....-•---•---------------•--••----•-----------•-•--.....---------------•---- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- i Permit No......................................................... Issued.....W, a� „ --� ate ... Date roNoFrV 4_4............... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN BARNSTABLE _ . ... . .............. F...................-........"...... . ........"....."-"'....................... Applirtttiun -for l spuiittl Works Tontitrnrtittn Prrniit Application is hereby made for a Permit to Construct (x ) or Repair ( ) an Individual Sewage Disposal System at: Pebble Path Lot 427 ------•---------•------•---------------•--------------------•---•-----.....--•---------........... ..-------•_..'•-----------•...-•--••......•--------•-•--•-••-•'----••-------------............ f f r��. / gLocc,3atiiopn-Address %/�,l y )/ or Lot No. ...................Car ...._r. eG- +.ti..8"3.t:.t:i J 1:.--___�-G`•4Y--a,-/'-�'�'•-__..... `l'•.' �tA_._.'`-y,' -'_-•_<C:'a[ ��Gl.x:e45•i--.}.-____•_________________________________ _ ......... �.r�.._ Owner Address s. Ae q .......................... ._._S�JY.S:_J__..#-_........................................... _Fi,. r•, ..................................... Installer Address UU Type of Building Size Lot....."......................Sq. feet Dwelling—No. of Bedrooms__"__"___.______-.3:......................Expansion Attic ( ) Garbage Grinder ( ) a4 Other—Type of Building ---------------------------- No. of persons.--------------------------- Showers ( ) — Cafeteria ( ) a' Other fixtures ------------------------------------ Design Flow--------//O:...........................gallons per per day. Total daily flow.............. 30---------------------gallons. W Septic Tank—Liquid capacity_lQQ__ allons Length 6_ 4 1`"1QB' .51 n g Width tameter Depth w x Disposal Trench—No. .................... Width___._"_____.___.___. Total Length.................... Total leaching area"______"____.-"_____sq. ft. � 1 267__-sC ft.Seepage Pit No.._."________________ Diameter Depth below inlet......17_........... Total leaching area------- _ 1. z Other Distribution box (X) Dosing tank ( ) aPercolation Test Results Performed by"_C4Lpe_..CQd---oldrmey...COTIS.LI-ltantBate....Aug-._-__8_R_-"19_71. Test Pit No. 1......2-------minutes per inch Depth of Test Pit"""_9______________ Depth to ground water--none___"__"_"- fX4 Test Pit No. 2________________minutes per inch Depth of Test Pit-------------------- Depth to ground water_____"________"__"_"""-" ---------_."---- - --"""-"-"--••"---•-"-"-"---...""---•--•--•--•-•-•--•-------------------------......................................................... -----...... ---•- ....__... _.....-•"---"-"--" U Description of Soil---Sand,56b©9�9 _a,��d3���►0��_ �aIZ:rn;�r-�-�x�l--��-Q---QX.a17(K�, �s!�."t�1........... - x P 9 U Nature of Repairs or Alterations—Answer when applicable.-______""______._"_"_""________________"__"_______-__-_""___--_" ------ -------------------------------------------------------------------------------- Agreement: The undersigned agrees to install.Ahe aforedescribed Individual Sewage Disposal System I 3 ter , the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to pl c� � e operation until a Certificate of Compliance has been issued by the board of health. �0 VAS EMI-' Sied.__ti"� --- _"r' ....-•----------------'•-•••"- A Application Approved B {, ,rl ate PP PP Y �! Application Disapproved for the following reasons:._._..____"_____."..............:.:....:....................................... ---•--------.Date ------------- --........-"--'-'"-'-•••'••-•--•-•••"""---_.______-"'_......._•""''' ----•--------------------------- --•-•-------•--_.---- f{� Date Permit No.............................................................. „-:< Issued..••--...... Date a [ v c.s THE COMMONWEALTH' OF MASSACHUSETTS r BOARD OF HEALTH O F. ell Trrtifirtttr of f. umplittnrr f THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (k, ) 'or Repaired ( ) by------------------------------------------ = R,_... s-• 1' F Installer at. turd14 �n'17 ------ . . .................. '" 1-' --__-_.-- -' ------------------------------------------------- has been installed in 'accordance with the provisions of A I XI of the State Sanitary Code as described in the application for Disposal Works Construction Permit No. ,�-."_. .__._.. dated_"_" ____ _ .. _7................... .. �� THE ISSUANCE OF THIS CERTIFICATE SHALL NOT*BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE"-'••--"-----"-•-'-'-•-••--------------- --------------------------------------- inspector...................................................................................... .. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ... ..OF...-.. .. ,..,............."................"-"._... t . 1?No. ...° FEE.--- ..... �i��n��ttl rrrk� �>an�t�nrti� t �rrmtt Permission is hereby granted--------- '------- ..--""--••-"-"""-----"-"'----"--"---"-""'..._.....-•"-"-"""""--••-----""-•----••--•----... to Construct . ) or. Repair ( ) an Individual Sewage Disposal System at Nosh ' try - ........ '1x 1`.......121412A....-...........k1 -,------ f' i r .................................................... Street as shown on the application for Disposal Works Construction Per 't No."___ti____________ Dated___f"".. _} 7.............. .......... " '- = ---------------------------------- DATE...... ..... --"--""-'"---"-'-"----'"---.....-••--•---------- FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS , LOCATION S SEWAGE PERMIT NO. P/2/�/3 G/t �i�T ,��t.�K� c u I s �� V 14 AGE INSTA LLER'S NAME & ADDRESS B U I'L D E R OR OWNER / DATE PERMIT ISSUED OAT E CO-MPLIANCE ISSUED Tab M6 Q IA 1 IA • O f � f / /* 1 5'F'e e—-----—---——MASY1,foo BOARD OF HEALTH T 0 Wr OF BARNSTABLE (,C Application for Well Congtruct ion Permit AXplication is hereby made for a permit to Construct ( 44,o"Alter or Repair ( )an individual Well at: - t __ &_ ^ Location Address Assessors Map and Parcel Owner Add 7 ------------------ Installer— Driller Address Type of Building Dwelling Other - Type of Building No. of Persons.-_-e�--- Type of Well Capacity Purpose of Well- I'm Agreement: The undersigned agrees to install the aforidescribed 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 u a Certifi ate f p i ce has been issued by the Board of Health. Signed date Application Approved By date Application Disapproved for the following reasons: date Permit No. Issued —-——------- date BOARD OF HEALTH TOWN OF BARNSTABLE Certificate Of Compliance THIS IS TO CERXH) ,, .the Ind:ivi ual Well Constructed (Altered or Repaired by--- Installer at P*V k 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 � s4• 1 0 o;J 8 51 a `f.S— No. ------ ------- i G , s��� Fee-------------- ----- BOARD OF HEALTH \ TOWN OF BARNSTABLE _ - ZippCicat ion for VelC Cottgtruct ion Permit Application is hereby made for a permit to Construct ( l Alter ( ), or Repair ( )an individual Well at: Location — Address Assessors Map and Parcel Owner��_ ---- —�'�F�"•�� GS �r3C�j�6�� �res.Add s6 sue,, Installer — Driller Address Type of Building Dwelling ---_-- -- -- ----- - i Other - Type of Building--=-____—__—_______ No, of Persons--. _ __..____—___ --__.__-- Type of Well C/lS c __— ---- 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 lace the well in operation until)a ertificate.of om P p ? p ' once has been issued by the Board of Health. Signed. ��_—_-- jn r date Application Approved By date Application Disapproved for the following reasons: date ' Permit No. — — ---- Issued---- -- -- ---____---- {/ date _---T.------- — — --------_-------.------------- .--------_ BOARD OF HEALTH TOWN OF BARNSTABLE Certificate Of Compliance THIS IS TO CERI=YF ,the Indivi ual Well Constructed (Altered ( ), or Repaired ( ) by-- ---- -- Installer at- - ��e 6 �c �q� . �2 s 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. Yell Con0ruct ion Permit Li No. Fee Permission is hereby granted to Construct (1'1,'Alte ( ), or R pair ( ) an Individu 1 Well at: Street as shown on the application for a Well Construction Permit No.-- _— Dated ( Board o Health DATE B46057 pea s CY �I X)r 4-N to 17 ell, 046051 37 ff, 4p, 046050 # 046049 #9 0 046047 • #44 AN D46048 Massachusetts Department of Environmental Protection r Bureau of Resource Protection - Drinking Water Program BRP WS06e Residential Units (four units or fewer) Registration of Underground Discharges to Injection Wells Modification to an Existing UIC Registration (BRP WS-06e) ❑ Questions Any questions may be directed to the UIC Program at(617) 348-4014 or to the UIC Contact at your. Regional MassDEP Office. Find your region: http://mass.gov/dep/about/region/findvour.htm Submit Application to: MassDEP Drinking Water Program 1 Winter Street—5th Floor, Boston, MA 02108 Attn: UIC Program MAILING ADDRESSES f , UIC Program, MassDEP Northeast Regional Office (NERO), 0 205b Lowell Street, Wilmington, MA 01887 ` UIC Program, MassDEP Southeast Regional Office (SERO), 20 Riverside Dr., Lakeville, MA 02347 UIC Program, MassDEP Central Regional Office (CERO), 627 Main Street, Worcester, MA 01608 UIC Program, MassDEP Western Regional Office (WERO), State House West, 4th Floor, 436 Dwight Street, Springfield, MA 01103 UIC Program, MassDEP Boston Office, One Winter Street—5th Floor, Boston, MA 02108 SERVICE CENTER PHONE NUMBERS: Northeast Regional Office 978-694-3200 Southeast Regional Office 508-946-2714 Central Regional Office 508-792-7683 Western Regional Office 413-755-2214 Send duplicate copies of all forms to: Local Board of Health Local-Plumbing Inspector ws06e[1]•rev.02/10 BRP WS06e-Residential Units•Page 5 of 5 T3. Massachusetts Department of Environmental Protection Bureau of Resource Protection - Drinking Water Program BRP WS06e Residential Units (four units or fewer) Registration of Underground Discharges to Injection Wells Modification to an Existing UIC Registration (BRP WS-06e) ❑ See Instructions UIC Registration Fee: check the appropriate category ® WS-06e. Residential Exemption (for four units or fewer) the following well types (typical residential activities) are exempt from a UIC registration fee: —1 5A7, 51D2, 5G30 & 5X18 See Instructions Transaction Type ;:y - Important:When filling out forms Registratio-v ® Initial- new registration ❑ Initial -existing registration ❑ Closure%Registration on the computer, use only the tab Modification: ❑ Change of owner/operator ( key to move your 9 ❑ Change in or additional w_efl/code(p's) cursor-do not use the return key. ElChange in location well(s) ❑ Change in#of discharge.wells (�/=y) For modifications (required) UIC Registration ID#issued by MassDEP in the original UIC Registration 1'l�t A. Residential Unit Information For modifications, enter only new or revised information. Jack Dellibovi Property namefPrivate Residence Company name(if different) 21 Pebble Fath Marstons Mill Property Street Address _City/Town MA 02648 Barnstable Water Suppljr: ® Public State Zip Code County ❑ Private 508-420-61;5 jdellibovi@whoi.edu Telephone Number Email(optional) See Instructions B. Owner/Operator Information For modifications, enter only new or revised information. Name of Owner Street Address City/Town State Zip Code Telephone Number Email(optional) Ownership Type: Private: ® Private ❑ Commercial ❑ Nonprofit ❑ Other: specify Public: ❑ Local ❑ Regional ❑ State ❑ Federal ws06e[1]•rev.02/10 BRP WS06e-Residential Units•Page 1 of 5 a - Massachusetts Department of Environmental Protection Bureau of Resource Protection - Drinking Water Program BRP WS06e Residential Units iL (four units or fewer) Registration of Underground Discharges to Injection Wells Modification to an Existing UIC Registration (BRP WS-06e) ❑ See Instructions C. Injection Well Information For modifications, enter only new or revised information. Registration: ® Individual or ❑ Area A See Instructions- 4 _�7Q �e�fii<ePw .J T 7 Table at end Well Type Well Code See Instructions Well Construction (check all that apply) Number of wells: Z ❑ Drywell ® Dug well ❑ Cesspool ❑ Septic Tank ❑ Drainfield/Leachfield ❑ Trench Drain ❑ Other(describe): See Instructions Type of Discharge: ® Geothermal Heat Pump.-open (5A7) ❑ Closed Loop Heat Pump (5A7) ❑ Groundwater Infiltration (5G30) ❑ Water Purification Discharge (5X18) ❑ Sump (5G30) ' ❑ Stormwater- roof drainage (5D2) ❑ Stormwater-other drainage List water purification units discharging to Class V well: See Instructions #of entrypoints to existing system #of entry points for proposed system Total#of entry points to system P 9 Y ryP P P Y ryP Y See Instructions 35 280 fine sand Depth to water table(ft) Depth to bedrock(ft) Soil type(s)at site See Instructions Distance to nearest private drinking water well(within 1250 feet) Month/Year of well construction See Instructions Distance to nearest Public Water Supply(within 2500 feet) Name of nearest Public Water Supply See Instructions .5 mile, 58 feet Distance to nearest wetland or water body Distance to nearest septic system D. Operational Status See Instructions Well Operation Status: ® Designed, not yet constructed ❑ Under Construction ❑ Active ❑ Temp. abandoned ❑ Conversion to another well type ❑ Partial Closure/conversion to another well type (well code) ❑ Permanently abandoned/ not reported previously ws06e[1]•rev.02/10 BRP WS06e-Residential Units•Page 2 of 5 Massachusetts Department of Environmental Protection Bureau of Resource Protection - Drinking Water Program BRP WS06e Residential Units (four units or fewer) Registration of Underground Discharges to Injection Wells Modification to an Existing UIC Registration (BRP WS-06e) ❑ E. Site Information Additional Information required: Must be attached injection well and to the All additional information that is relevant to the installation or operation of this in -see Instructions P 1 determination of its potential to endanger underground sources of drinking water(USDWs)— including a site map showing the facility and UIC well(s), on-site drinking water wells, all other on-site discharges and the drains leading to the well and/or drainage area served by the well. MSDS sheets for chemicals likely to be discharged into well must be submitted. Who must register: Any party who discharges to a Class V Well as defined in 310 CMR 27.00 must apply except those listed as exempt from the registration requirement as per 310 CMR 27.07. If you have not previously registered and you are closing the use of the well(s)for one(or more) uses but want to continue using the well(s)for one.(or more) uses you must mark the top of this form Change in or Additional Well Code(s) and attach to this submittal a Pre-Closure Form for the well(s)/activities being closed. If you have not previously registered and you are converting the well from a``prohibited" use to a use that is"authorized by rule" you must mark the top of this form Conversion Change in or Additional Well Code(s) and attach to this submittal a Pre-Closure Form for the well(s)/activities being closed. Who must submit a Modification Form: If the Owner or Operator information changes you must notify the UIC program at least 30 days prior' to the change(s). If you are adding wells (Area Registration); relocating the well(s), changing the discharge (Well Code) to the well(s) or adding additional discharges (Well Code) you must notify MassDEP at least 60 days prior to the change. If you are closing the well(s) and relocating the well(s) and are planning to have the same discharge (Well Code), you must mark the top of this form Relocation of Well(s) and attach to this submittal a Pre-Closure Form for the well(s) being closed.. Fee Residential units (four units or fewer) effective 10/08/04 are exempt from the UIC application fee (no Transmittal Form needs to be submitted)for residential activities. There is no application fee associated with submitting a Modification application to an existing registration. BRP WS-06e- Residential Unit(4 units or fewer)/ Residential Activity—Fee Exempt No Transmittal Form (or number) is needed when submitting a Modification to an existing Registration. There is no annual compliance fee associated with this Registration. ws06e[1]-rev.02/10 BRP WS06e-Residential Units•Page 3 of 5 - Massachusetts Department of Environmental Protection Bureau of Resource Protection - Drinking Water Program BRP WS06e Residential Units (four units or fewer) Registration of Underground Discharges to Injection Wells Modification to an Existing UIC Registration (BRP WS-06e) ❑ F. Affidavit The injection well(s)described above is used for placement or injection of fluids into the ground. I/we understand that this well is subject to inventory requirements and compliance with the regulations under the Underground Injection Control Program established pursuant to the Safe Drinking Water Act, P.L. 93-523, and amendments, and I/we hereby serve notice that the well is proposed or in service. I/we agree: 1. That the well(s) described herein will not be used for discharges other than those described above; 2. That l/we will notify the MassDEP Drinking Water Program/UIC Program (on forms provided by the UIC program) if any of the information (including Ownership, Location or Type of discharge) for the above well(s) changes, but before the change (30 days minimum notice on ownership/operator and 60 day notice on all other changes); 3. That I/we will notify the MassDEP Drinking Water Program/UIC Program (on forms provided by the UIC program—Pre-Closure Notification Form)when the above well(s) is no longer in use, but before abandonment and file a Post-Closure Notification Form within seven days of completing the closure with the UIC program. 4. That I/we will maintain financial responsibility for the well described above; and 5. That I/we will provide a sampling tap (approved by MassDEP) and allow sampling at the point of injection. I/We certify under penalty of law that I/we have personally examined and am familiar with the information submitted in this document and all attachments and based on my personal knowledge or inquiry of those individuals immediately responsible for obtaining the information, I/we believe the information is true, accurate, and complete. I/we am aware that there are significant penalties for submitting false information, including possible fines and imprisonment. 2/28/2011 Signature Date Robert J. Franey, Jr. Pres. RJ Franey Mechanical Services. Printed name of preparer Positionrritle J:_C-6 Pi4 4 Z 7 7 56 —0 2-10 ws06e[1]•rev.02/10 BRP WS06e-Residential Units•Page 4 of 5 Town of Barnstable Geographic Information System February 24, 2011 so Me k�, 046051 046050 #21 c T z 046oa9 c, r #9 Az � 2�I� , 046046 # #58 Q 046047 r #44 �.<.. 0 12 Feet 046048 DISCLAIMERS:This ma is for planning purposes only. It is not adequate for legal Map:046 Parcel:050 P P t P P Y g 9 boundary determination or regulatory interpretation. Enlargements beyond a scale of Selected Parcel Owner:DELLIBOVI,JACK Total Assessed Value:$ 0 , 1"=100'may not meet established map accuracy standards. The parcel lines on this map are only graphic representations of Assessor's tax parcels. They are not true property Co-Owner: Acreage:0.46 acres Abutters , boundaries and do not represent accurate relationships to physical features on the map Location:21 PEBBLE PATH t such as building locations. � Buffer 40go 1 Nil met "�� 1 10, , 3 Pft 1 1 r� ¢' } Epp 3s 3 vy IF,ly l�v 1 T I age 10 of I I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSE SSMENTS SUBSU RFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 21 PEBBLE PATH MARSTONS MILLS, MA 02648 Owner: TERESA KOZAK Date of Inspection: 6/22/01 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 where public water supply enters the building. r> A L°I p g C AC $3 �� by Massachusetts Department of Environmental Protection j c1 Z Bureau of Resource Protection f WELL DRILLER Please specify work performed Address at well location: New Well Street Number: Street Name: 21 PEBBLE PATH Please specify well type: Building Lot#: Assessor's Map#: GeoThermal Open Loop _ F- Assessor's Lot#: ZIP Code: Number Of Wells: o2648 City/Town: Well Location BARNSTABLE In public right-of-way: GPS r.Yes r No North: West: 41.67878 70.43159 Subdivision/Property/Description Mailing Address: click here if same as well location address Property Owner: Street Number: Street Name: DELLIBOVI 21 PEBBLE PATH City/Town: State: Engineering Firm: IBARNSTABLE _y MASSACHUSETTS - I ZIP Code: 102648 Board of health permit obtained: LG..-Yes C'ss Not Required ..----....._.-.------._._,. Permit Number: Date Issued: W2011009 6/7/2011 Massachusetts Department of Environmental Protection Bureau of Resource Protection—Well Driller Program Well Completion Reports(General) Well Driller - General Well Form DRILLING METHOD Overburden Bedrock. FChooAuger se Bedrock-- WELL LOG OVERBURDEN LITHOLOGY From To(ft) Code Color Comment Drop in Extra fast or slow Loss or addition of (ft) drill stem drill rate fluid F207 Fine To Coarse Sand Brown (�Yes; G Fast G Slow G Loss G Addition 20 F4_61 Fine To Coarse Sand Brown ir Yes G Fast G Slow G Loss Addition 40 F507 Fine To Coarse Sand Brown ( Yes G Fast G Slow G Loss Addition 50 55 Medium Sand Brown r Yes G Fast G Slow G Loss G Addition 55 65 Fine To Coarse Sand Brown r Yes: G Fast G Slow r LOSS G Addition WELL LOG BEDROCK LITHOLOGY Visible Extra From Drop in Extra fast or slow Loss or addition of To(ft) Code Comment Rust Large (ft) drill stem drill rate fluid r Staining Chips Choose Code r Ye G Fast G Slow' G Loss G Addition r Ye Yes ADDITIONAL WELL INFORMATION Developed {"Yes 0 No Disinfected Yes C} No Total Well Depth 65 Depth to Bedrock Fracture Surface Seal Type jNona Enhancement 'Yes �� No CASING r�Is Casing above ground? From: To: 0 From To Type Thickness Diameter Driveshoe 0 62 Polyvinyl Chloride Schedule 40 4 r Yes SCREEN ❑No Screen From To Type Slot Size Diameter 62 65 Stainless Steel Well Point 0.010 WATER-BEARING ZONES I F_.i DRY WELIJ From To Yield (gpm) 41 65 15 PERMANENT PUMP(IF AVAILABLE) 3 Wire Variable Speed Pump Description Horsepower Submersible 1 1/2 Y Massachusetts Department of Environmental Protection ,._ Bureau of Resource Protection—Well Driller Program Well Completion Reports(General) Pump Intake Depth(ft) 162 Nominal Pump Capacity(gpm) 115 ANNULAR SEAL/FILTER PACK Water ,From To Material 1 Weight Material 2 Weight(gal) Batches Method Of Placement Choose Material Choose Material Choose One-- 1C 0 .0 GEOTHERMAL INFORMATION Thermal Conductivity Thermal Diffusivity Formation Water Sample taken (BTU/hr.ft.°F) (ft2/day) Temperature(°F) DEP UIC# from this well? MAS 1A 41 0-20218 'Yes 'No!, WELL TEST DATA L Time Pumping Time To Date Method Yield (gpm) -Pumped Level (ft Recover Recovery (ft (HH:MM) BGS) (HH:MM) BGS) 6J2912011 Constant Rate Pum 15 1:30 43 0:01 �41 WATER LEVEL Date Measured Static Depth BGS (ft) Flowing Rate (gpm) 6/29/2011 141 15 COMMENTS WELL DRILLERS STATEMENT This well was drilled or altered under my direct supervision,according to the applicable rules and regulations,and this report is complete a knowledge. Driller THOMAS E DESMOND III Registration# 1764 1 Monitoring[M] Supervising Drill Firm DESMOND WELL DRILU Rig Permit# 1023 Date Job Compl NOTE:Well Completion Reports must be filed by the registered well driller within 30 days of well completion. 1318057 #18 i - z< pea a+ -04 PA ri, i ks , Well 437 046050 046047 #44 °- AIN 046048 ENVIROTECHLABORATORIES,INC. MA CERT. NO.:M-MA 063 8 Jan Sebastian Drive Unit 12 Sandwich,MA 02563 (508)888-6460 1-800-339-6460 FAX(508)888-6446 Client Name Desmond Well Drilling Location 21 Pebble Path Address PO Box 2783 Marston Mills,MA Orleans MA 02653 Sample Date 06/29/11 Collected By Desmond wells Sample Time 14:30 Sample Type New Well Date Received os/3o/11 Lab Order Number DW-111639 Well Specs 4"SCH40 PVC/.65'/40' Location Source Date Collected Time Collected Comments - A sns/1r - laso ._._ _. Analysis Requested Units Recommended Limits Analysis Result Method Date Analyzed Analyzed By Total Coliform /100ml 0 0 SM9222B 6/29/2011 RS Comments: e.Saarl DateRon Laboratory Direct BRL=Below Reportable Limits 'See Attached Page 1 of 1 ❑Certication is not available for this analyte for non potable water samples.. "ifk Massachusetts Department of Environmental Protection ' -' Bureau of Resource Protection / WELL DRILLER Please specify work performed: Address at well location: New Well Street Number: Street Name: __-_-----� 21 PEBBLE PATH Please specify well type: Building Lot#: Assessor's Map#: Geothermal Open Loop Discharge Well Assessor's Lot#: ZIP Code: Number Of Wells: 02648 City/Town: Well Location BARNSTABLE In public right-of-way: GPS Yes r No North: West: 41.67881 170.43159 Subdivision/Property/Description: Mailing Address: click here if same as well location address Property Owner: Street Number: Street Name: DELLIBOVI 21 PEBBLE PATH - --— �i City/Town: State: Engineering Firm: JBARNSTABLE MASSACHUSETTS ZIP Code: 02648 Board of health permit obtained: C*)Yes G Not Required Permit Number: Date Issued: W2011009 6/7/2011 Massachusetts Department of Environmental Protection Bureau of Resource Protection—Well Driller Program Well Completion Reports(General) Well Driller - General Well Form DRILLING METHOD Overburden Bedrock (Auger -Choose Bedrock-_� WELL LOG OVERBURDEN LITHOLOGY From To(ft) Code Color Comment Drop in Extra fast or slow Loss or addition of (ft) _ drill stem drill rate fluid 20 _Fine To Coarse Sand Brown Yes r Fast GJ Slow r Loss Addition, ... 20 40 x Fine To Coarse Sand Brown J r Ye r Fast Slow Loss Addition 40 50 Fine To Coarse Sand Brown ( Yes 0 Fast f�Slow 0 Loss Addition WELL LOG BEDROCK LITHOLOGY _ - Visible Extra From Drop in Extra fast or slow Loss or addition of To(ft) Code Comment Rust Large (ft) drill stem drill rate fluid Staining Chips Choose Code — 0 Ye a Fast Slow r Loss Addition Ye r Ye ADDITIONAL WELL INFORMATION Developed (: Yes 0 No' Disinfected (F)Yes CD No Total Well Depth I50 -- Depth to Bedrock Fracture Surface Seal Type None Enhancement f i Yes Co� No CASING F Is Casing above ground? From: �1 To: � From To Type Thickness Diameter Driveshoe 10 Polyvinyl Chloride Schedule 40 �_ _-__I [S-� 1 SCREEN r No Screen From To Type Slot Size Diameter 10 50 Continuous Wire PVC 0.010 WATER-BEARING ZONES rDRYWEL From To Yield (gpm) 41 50 15 PERMANENT PUMP(IF AVAILABLE) Choose Pump --Choose Horsepower-- Pump Description Horsepower Description--- Pump Intake Depth(ft) —� Nominal Pump Capacity(gpm) — ] I r-- Massachusetts Department of Environmental Protection ' Bureau of Resource Protection—Well Driller Program _? Well Completion Reports(General) ANNULAR SEAL I FILTER PACK Water From To Material 1 Weight Material 2 Weight(gal) Batches Method Of Placement (� (Choose�Materizl (�� Choose Material Choose One-- GEOTHERMAL INFORMATION Thermal Conductivity Thermal Diffusivity Formation Water Sample taken (BTU/hr.ft.°F) (ft2/day) Temperature(°F) DEP UIC# from this well? MAS 1A 41 0-20218 C Yes C No WELL TEST DArA Time Pumping Time To Date Method Yield(gpm) Pumped Level (ft Recover Recovery (ft BGS) (HH:MM) BGS) (HH:MM) 6129l2011 Constant Rate Pump 0:01 41 0:01 41 WATER LEVEL Date Measured Static Depth BGS (ft) Flowing Rate (gpm) 6l30/2011 41 115 COMMENTS WELL DRILLERS STATEMENT This well was drilled or altered under my direct supervision,according to the applicable rules and regulations,and this report is complete a knowledge. Driller THOMASEDESMONDIII Registration# 764 Monitoring[M] Supervising Drill Firm DESMOND WELL DRILLI Rig Permit# 023 Date Job Compl NOTE:Well Completion Reports must be filed by the registered well driller within 30 days of well completion. 1 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION d � , d a e� i� ,11b TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 21 PEBBLE PATH MARSTONS MILLS, MA 02648 Owner's Name: TERESA KOZAK Owner's Address: 21 PEBBLE PATH MARSTONS MILLS,MA 02648 Date of Inspection: 6/22/01 Name of Inspector: (please print) JOHN GRACI Company Name: SEPTIC INSPECTIONS Mailing Address: P.O. BOX 2119 TEATICKET, MA.02536 Telephone Number: 508-564-6813 FAX 508-564-7270 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 DEN approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: X Passes _ Conditionally Passes _ Needs Further Ev luation by the Local Approving Authority Fails Inspector's Signature: Date: 6/22/01 ti The system inspector shall submit a opy 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 Comments SYSTEM PASSES TITLE V INSPECTION. RECOMMEND PUMPING SYSTEM EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE. -RECOMMEND REMOVING TREE AND ALL BUSHES OFF OF SYSTEM- RECOMMEND RAISING COVER OF LEACH PIT ****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 Incnvrfinn Rrn•ni ril snnnn I Page 2 of I I OFFICIAL INSPECTION-FORM—NOT FOR VOLUNTARY ASSESSMENTS y SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 21 PEBBLE PATH MARSTONS MILLS, MA 02648 Owner: TERESA KOZAK Date of Inspection: 6/22/01 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X 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 PASSES TITLE V INSPECTION. RECOMMEND PUMPING SYSTEM EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE.-RECOMMEND REMOVING TREE AND ALL BUSHES OFF OF SYSTEM- RECOMMEND RAISING COVER OF LEACH PIT 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. n/a 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. ND explain: n/a i n/a 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: n/a n/a 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: n/a Page 3 of 1 I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS y SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 21 PEBBLE PATH MARSTONS MILLS,MA 02648 Owner: TERESA KOZAK Date of Inspection: 6/22/01 C. Further Evaluation is Required by the Board of Health: A _ 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(i)(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 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 I 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 n/a "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: n/a z Page 4 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 21 PEBBLE PATH MARSTONS MILLS, MA 02648 Owner: TERESA KOZAK Date of Inspection: 6/22/01 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for alLinspections: Yes No X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X Liquid depth in cesspool is less than 6" below invert or available volume is less than !% day flow X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped nLa. X Any portion of the SAS,cesspool or privy is below high ground water elevation. X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or,privy is within a Zone 1 of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well. X 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.l (Yes/No)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. 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 X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area— I W PA)or a mapped Zone 11 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 L' or failed under Section D shall upgrade(lie system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. r n r -" Page 5 of 1 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS ` SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 21 PEBBLE PATH MARSTONS MILLS,MA 02648 Owner: TERESA KOZAK Date of Inspection: 6/22/01 Check if the following have been done. You must indicate "yes" or"no" as to each of the following: Yes No X _ Pumping information was provided by the owner,occupant,or Board of Health X Were any of the system components pumped out in the previous two weeks'? X _ Has the system received normal flows in the previous two week period `? X Have large volumes of water been introduced to the system recently or as part of this inspection r ,Were as built plans of the system obtained and examined?(If they were not available note as N/A) X _ Was the facility or dwelling inspected for signs of sewage back up? X _ Was the site inspected for signs of break out? X _ Were all system components, excluding the SAS, located on site? X _ 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 ? X 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 X _ Existing information. For example,a plan at the Board of Health. X _ 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 IPage6 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 21 PEBBLE PATH MARSTONS MILLS, MA 02648 Owner: TERESA KOZAK Date of Inspection: 6/22/01 FLOW CONDITIONS RESIDENTIAL 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 Number of current residents: 2 Does residence have a garbage grinder(yes or no): NO Is laundry on a separate sewage system(yes or no): NO [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)): n/a Sump pump(yes or no): NO Last date of occupancy: n/a COMMERCIAL/INDUSTRIAL Type of establishment: n/a Design flow(based on 310 CMR 15.203): n/agpd Basis of design flow(seats/ipersons/sgft,etc.): n/a Grease trap present(yes or no): NO Industrial waste holding tank present(yes or no): NO Non-sanitary waste discharged to the Title 5 system (yes or no): NO Water meter readings, if available: n/a Last date of occupancy/use: n/a OTHER(describe): n/a GENERAL INFORMATION Pumping Records ` Source of information: n/a Was system pumped as part of the inspection (yes or no): NO If yes,volume pumped: n/agallons-- Howwas quantity pumped determined? n/a Reason for pumping: n/a TYPE OF SYSTEM X 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) _Tight tank Attach a copy of the DEP approval Other(describe): n/a Approximate age of all components,date installed(if known)and source of information: 1977 Were sewage odors detected when arriving at the site(yes or no): NO 6 Page 7 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 21 PEBBLE PATH MARSTONS MILLS,MA 02648 Owner: TERESA KOZAK Date of Inspection: 6/22/01 BUILDING SEWER(locate on site plan) Depth below grade: 14" Materials of construction:_cast iron =40 PVC Xother(explain): 20 PVC Distance from private water supply well or suction line: n/a Comments(on condition of joints,venting,evidence of leakage,etc.): n/a SEPTIC TANK: (locate on site plan) Depth below grade: 8" Material of construction: Xconcrete_metal_fiberglass_polyethylene other(explain)n/a If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate) Dimensions: IOOOG L 8' 6" H 5' 7" W 4' 10 Sludge depth:3" Distance from top of sludge to bottom of outlet tee or baffle: 31" Scum thickness: 4" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: 14" How were dimensions determined: 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.): THE SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE SYSTEM GREASE TRAP:_(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a 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/a Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): n/a Page 8 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 21 PEBBLE PATH MARSTONS MILLS,MA 02648 Owner: TERESA KOZAK Date of Inspection: 6/22/01 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: 0" Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Capacity: n/a gallons Design Flow: n/a gallons/day Alarm present(yes or no): N/A Alarm level: N/A Alarm in working order(yes or no): NO Date of last pumping: n/a Comments(condition of alarm and Float switches, etc.): n/a DISTRIBUTION BOX: X(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: n/a 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.): DOD NOT EXPOSE-UNDER GARDEN-SYSTEM SHOWS NO SIGNS OF FAILURE. PUMP CHAMBER: _(locate on site plan) Pumps in working order(yes or no): NO Alarms in working order(yes or no):NO Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): n/a Page 9 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 21 PEBBLE PATH MARSTONS MILLS, MA 02648 Owner: TERESA KOZAK Date of Inspection: 6/22/01 SOIL ABSORPTION SYSTEM (SAS): X (locate on site plan,excavation not required) If SAS not located explain why: n/a Type 1000 GAL 6' X 6' leaching pits, number: n/a leaching chambers, number: n/a n/a leaching galleries, number: n/a n/a leaching trenches, number, length: n/a n/a leaching fields, number: n/a n/a overflow cesspool, number: n/a n/a innovative/alternative system Type/name of technology: n/a Comments(note condition of soil, signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.): THE LEACH PIT APPEARS TO BE FUNCTIONING PROPERLY-.NEVER MORE THAN HALF FULL- OCTAGON SHAPED. RECOMMEND RAISING COVER. CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: n/a Depth—top of liquid 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 or no): NO 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 f Page 10 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 21 PEBBLE PATH MARSTONS MILLS, MA 02648 Owner: TERESA KOZAK Date of Inspection: 6/22/01 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 where public water supply enters the building. bec k E II� A ng Aq ly �g �a Pc �y Page I I of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 21 PEBBLE PATH MARSTONS MILLS,MA 02648 Owner: TERESA KOZAK Date of Inspection: 6/22/01 SITE EXAM _Slope _Surface water _Check cellar Shallow wells Estimated depth to ground water 12 feet Please indicate(check)all methods used to determine the high ground water elevation: NO Obtained from system design plans on record-If checked,date of design plan reviewed: n/a NO Observed site(abutting property/observation hole within 150 feet of SAS) NO Checked with local Board of Health-explain: n/a NO Checked with local excavators, installers-(attach documentation) YES Accessed USGS database-explain: n/a You must describe how you established the high ground water elevation: USGS MAPS AND CHARTS- 12 FEET THE FOLLOWING IS/ARE THE BEST IMAGES FROM POOR QUALITY ORIGINALS) M DATA FOUNDATION by c-sraTtg'y -r ja I Y& WASHED STONE--,-", SCALE I"= 4 10 Pane. PATa TtiF- Toua.,'? 51- y' J 8 TEST BY : z '.t.4 s r . TOWN INSPECTOh: BACKHOE OPERATOR : TEST MADE ON : rk L E IB7 I-A)4 ;RAT, /.Iyg 72 s-;'4-4 CAj W +1 LOT 4 `� - zo. lo o -35' ± N-) N 137 .Owl % 0) I4,o •B �' IN'V ►3 SS \ \ 0 tl S-OUTLE.T vlo x ............ 14o ---------- lalry r;ELEVATION SCHEDULE -ROPPOGED BITE PLAN I. INV. AT FOUNDATION 15 8 2. INV. INTO SEPTIC TANK 3917AO-E SYSTEM DESION c' IN 3. 1 NV. OUT OF SEPTIC TANK 4. INV. INTO DISTRIBUTION 80.X 19 SCALE: 5 INV OUT OF DISTRIBUTION BOX 7 S 8 c- 6. INV INTO SEEPAGE PIT 1U.-9e) CAPE COD SURVEY CONSULTANTS ROUTE 132 T. BOTTOM OF PIT spa IBO- HYANNIS,MASS, I � ow'� - ---- _---+--_ -_-- l� C A P E A R C HITEC T U RE I Pli WUX 645,DARN STAULF, t� M A SSACHUSETTS 02637 T-51-IR 367 5900 E-KMB_I1;CAPEARC.Il"FCIURG.NET W W W.CAHCAHUHITCCTURE.NET GENERAL NOTES: 1.ALL CX'I LRI:JW WALLS SHALT_ BE 2X6.il 16"G.C.I.INLESS NU'IEU OTHFRWI.SE. _ 2.ALL INTER NAL WALLS SHALT. BE 2X/. i]'l 1 6"O.U.UNLESS NUIEi:UIHERWISE 3.UUNI RACTOR SHALL VERIFY ALL WINDOW OPE NI Nli PR;OR TO ORDF_RINr W Nou'W i. CONTRACTOR SHALL VLNit Y A_L OIMENSIO�IC PRIOR TO CON UI RUCTION.CCNTRAI'Tr.P ASSUMES RES.PONSISILI-Y FOR A N V MISSING OR NUURRECT DIMCNSIONS NOT BROUGHT TO THE DESIGNERS ATTENTION. ENGINEER: JOHN C SPINK 57 CLAY STREET, -...__.. _-_._._. _.. ... ... _.._ __.-..., _...._.. - - MIDDLEBORD, MA . _ . =:. La Ar D 91 i i � PE E _ KITCHEN �veR it BEDROOM - --. •, BEDROOM N ........... DIING -� E rrancr .... I ROOM ¢cranr.T - :' cLa sET WAIL aE.Mo:Ec __ _ RCLRDA. LD -� POW ER " j �I/_ aHowea CLOSET i CLOSET DDOR IN OR N.N 2 FLO .. ._ N ` ' EL - I - i _-------- NEW WALL :. _ �' ,• � -- � I ( i it x UVCR - - OVUER CLD HTT i ...... O PENINc - LIVING ROOM LrI NEW WDINDDw CL wINOOW 1 I I I 1 y�uVEa z FLooR o 1 'I� ' "I ANBEDRODM \ ++ U ooEo ro I 1. r cYL I•c ro _ I ��rTom of _ 'c.ANG z ( -� .� , ..• Ew cARHEas N w',Noeas .. ,. - oVPO RGH ROOF srwr:DING I II senrn a PPEP I--L_ .I! - .. � I rfiNu,NG Lc� p I SEAM COPPER REV. NOTES. DATE [I ,� NEW sAR wIERB ORGH ROCI __._ _— NEp EN nRRaor - ''`I` ••" I �srnNolNG I I i REVISIONS: - — ' L L Scam COPPER _ j -- Fl U STANu1NG � -. FARMERS PORCH -a sEAM coPPea �i —�+ SCALE: _IFT :' - -- -_-_. D DATE:azaal9 A, PROJECT: n - -- 5'•H�;," / - v / s-.n / - PROPOSED - � ^ a `Y/ y ti .o.l oE�eeroR FRONT ADDITION (� oNop ucE r. 91 D` a}K,v. _. ,N. PRO PO BED FIRST FLOG �1NLP1N T•;. 2 PROPOSED SECOND FLOOR PLAN q� 1 FT. 3 PROPOSED ROOF PLAN 4 - 1 FT. LOCATION: Al Al Al JIM & RAM BELLIBOVI, 21 PEBBLE PATH MARST13NS MILLS. MA DWG.TITLE: PROPOSED PLANS, 1' PROJECT NO. 191 1 " DWG. NO. 1 ( A ■ 774-7663$g4 j,p,rkl@gmcII.com,, CAPE ARCHITECTURE EXPRESSLY 411SERVES ITS COMMON LAW COPYRIGHT THESE PL A—ARE NOT TO BE REPRODUCED CR C7PIED N ANY TORM,WITHOUT FIRST UUTAINING ff ' $OIL Loe 1 \XyFIduICY \VnnY•aSIX•rrr.iid.Ei.(�wv , .. 2 .PEASTONE LOAM 6 FILL 12"MAX. 110.3+•'_^_ v— T_ / � o o l S t BOX I, o •! ' e ° 1000 -) z.°MIN: Ise, :.' 1000— .GAI. � °off_ GAL. •''„ PRECAST OR ° ° •I SEPTIC 6'I BLOCK °° G eA v e t- TANK l 3 V, (( i� :.e ! SEEPAGE PITS D I -SAMD d " 20' MINIMUM --�-{�,,° • °0 1p ° , - — FOUNDATION 13�• I %: WASHED STONE 1 h='QE hit crn`TiF�r }�aT �'kt, '3T_auc"'f,`�i9a,, I !I/Q Ir✓.47E 54d,N hEq�,,�N. was LoGATsrb by *" *047"u4G I SCALE: 1": 4' %e JSY e,N /q r r� G(�M rC �ts, , r 10 R C. 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