HomeMy WebLinkAbout0916 SANTUIT-NEWTOWN ROAD - Health 916 Santuit-Newtown Road
Marstons Mills P
'h
� a2 V-0 a$ Fee—q-a---'------
BOARD OF HEALTH
TOWN OF BARNSTAB LE
App[icationArlVe[i Con5trurtion30ermit
Application is hereby mad for a permit to Construct ( ), Alter ( ), or Repair (f,�in individual Well at:
Location — Address Assessors Map and Parcel
_ �� �� -- - - --- ------------- - --- -
/ Owner Address
-------------—--------------------- --- --- - - -
Installer — Driller Address
Type of Building ��/'
Dwelling x1 °-- ----------- —
Other - Type of Building------------- - - No. of Persons--y-----------------------
er
Type of Well— --� --- —_—_ Capacity---— -- —--— ----- ———
Purpose of Well----�o�� ---------
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 !�CZL —-——-------- - — --=( `f/c —
date
D UAW
7)
Application Approved By 3
---- ° -------—— v o -
te
Application Disapproved for the following reasons: --------— - - --- -- -------
----- ---------------------------------- -----
-- — — date
. 'n �-7 1.
Permit No.,j.uL) o� —--- Issued--1 36)0 ------ — ——
date
BOARD OF HEALTH
TOWN OF BARNSTABLE
C ertif irate Of C=Phanre
THIS IS TO CERTIFY, That the Individual Well Constructed ( ), Altered ( ), or Repaired
Installer
at--- 1fp /l/ef 4`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 Dated--� (!�,�-
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL
SYSTEM WILL FUNCTION SATISFACTORY.
DATE----- - — Inspector-- - ----------------------- -------
—_No. —��11 y'D C�0 Fee---`-`- - ------
� ---
BOARD OF HEALTH -
N. OF BARNSTAB�
TOW"
I� E
Y
.�µ ApplicationArIvell conoruction Permit
Application is hereby made for a permit to Construct ( ), Alter ( ), or Repair (ri-)an individual Well at:
07
r ,, _Location`—, A —?— As�mrs Map and Parcel
Owner Address
fl___.�/o�.fs'.q/L / �F9 _c ��! �Y✓_— ——— ----—--------—----—----------------—— -- --— -- —
Installer — Driller Address
Type of Building r
Dwelling
Other - Type of Building----------------- - No. of Persons-- ---------------------
Type of Well�!( --- ------ — Capacity--- — ---——---
Purpose of Well �r�a ,f�---- ----- —
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--o— V!�w
date
Application Disapproved for the following reasons:-------- - - --- — - ---— "yr
---—------ - ----------------------------------- — ---
n -�7 date
Permit No.���G0 — Issued--�/� � V date
-- ---— -----
BOARD OF HEALTH
TOWN OF BARNSTABLE
(Certificate ®f ComPliante
THIS IS TO CERTIFY, That the Individual Well Constructed ( ),-Altered ( ), or Repaired ((,,4
f
-- --------------- - - -- - -- --- ----
rr Installer
at
� '✓-—� `` °r 9 f S`j.,.Ste/ �f--- --- -------------
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.L"—��� ��a Dated-- Y-
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL
SYSTEM WILL FUNCTION SATISFACTORY.
DATE----- —-- - -- Inspector-- - —-- - --- — —
f
BOARD OF HEALTH
TOWN OF BARNSTABLE
Vell con$tructionpermit
No. Fee
Fee Permission is is hereby granted Q - C�'"'^ `� - {A ' d V`II) --_--_--
to Construct ( ),1 Alter (,,),-�r Repair (V�)�an Individual Well at:
7-
No. /I 10, c{,, -I --- - tf t- ----- -- ------- — -- - —- - - -
-Ll a�� street
as shown on the application for a Well Construction Permit
Ou �_ U� -- Dated—� ��
No.-- boI6
U,. -5------------------------------
Board of Health
DATE --
TOWN OF B.ARNSTABLE
LOCATION SEWAGE # _
VILLAGE2qg&A ASSESSOR'S MAP & LOT
INSTALLER'S NAME 6a PHONE NO.ad-
S15PO,C TANK CAPACITY
r
LEACHING FACILITY:(type) uf=)
NO. OF BEDROOMS PRIVATE WELL OR
BUILDER OR OWNER
DATE PERMIT ISSUED: ^ I QA2
DATE :COMPLIANCE ISSUE'. "02
VARIANCE GRANTED: APM. _,,No
u
alb �`
i
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTNzNT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
owl-w i PARTA MAP T_
CERTIFICATION PARCB. • o
f \ . J
Property Address: LOT
�.r7&K / fig' Z 3(P Z
Owner's Name-
`
Owner's Address: 1A ���,� A v4--
1 rnv�4 ri3
Date of Inspection: // 6 Z RECEIVED
Name of Inspectors(please print) e—
Company Name: �r ` e ,/ ;, FAPR 0 2 2002
Mailing Address: 'a N.
r° r i/f rlr4 0--12 TOWN OF BARNSTABLE
Telephone Number. .5g-,4C- �(o� V0 HEALTH DEPT.
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 fimction and maintenance of on site sewage disposal systems.I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 1S.000� The system:
Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority.
Fails
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.Theariginal should be sent to the system owner and copies sent to the buyer,if applicable,and the approving
authority.
Notes and Comments
****Phis 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.
i
Page 2 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 91A;
r
Owner. n
Date of Inspection•
Inspection Summary: Check AAC,D or E I 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
15.3 3 or in 310 CUR 15.304 exist.Any failure criteria not evaluated are indicated below.
Comments:
B.. System Conditionally Passes:
One or more system components as described in the"Conditional Pass"section need to be replaced or
repaired.The system,upon completion of the replacement or repair,as approved by the Board of health,will pass.
Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please
explain.
The septic tank is metal and over 20 years o1d*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:
Observation of sewage backup or break out or high static water level in the distribution box due to broken.or
obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain: _ _
Page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: C?JC
� r
Owner:
Date of Inspection: 1 I
C. Further Evaluation is Required by the.Board of Health: �f r
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 envim ment.
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
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 coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered.A copy of the analysis must be attached to this form.
3. Other:
Page 4 of 1 I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: l 16 1>j
Owner.
Date of Inspection: a
D. System Failure Criteria applicable to all systems:
You must indicate`yes"or"no"to each of the following for a�1 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
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 fleet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. [This system passes if the well water analysis,
performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered.A copy of the analysis mast be attached to this form.]
(Yes/No)The system!ails.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�Vdm the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd
You must indicate either`yeC or"no"to each of the following.
(The following criteria apply to large systems in addition to the criteria above)
Yes no
the system is within 400 feet of a surface drinking water supply
_ the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped
Zone II of a public water supply well
If you have answered Ayes"to any question in Section E.the system is considered a significant threat,or answered
"yesA 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 a=rdance with 310 CMR
13.304.The system owner should contact the appropriate regional office of the Department.
Page 5 of l l
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: et-J' cA dde) DIJ
Owner: r,; e
Date of Inspection: /S
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?
k_ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition
oi;aiues 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 sue and location of the Soil Absorption System(SAS)on the site has been determined based on:
no
Existing information.For example,a plan at the Board of Health.
Determined in the field(if any of the fAure criteria related to Part C is at issue approxitnation of distance
is unacceptable)[310 CMR 15.302(3)(b))
Page 6 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: // l t y
Owner: SCE, �t ems'
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):'
Number of current residents: 0,
Does residence Bove a garbage grinder(yes or no): �
Is laundry on a separate sewage system(yes or no):=[if yes separate inspection required]
Laundry system inspected es or no):�;U7
Seasonal use:(yes or no): Q
Water meter readings,if available(last 2 years usage(gpd)): 6 V
Sump pump(yes or no): �
Last date of occupancy: r-
COMMERCUL1 NDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203 : god .
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no):i
Non-sanitary waste discharged to the Title 5 system(yes or no):_
Water meter readings,if available:
Last date of occupancyhm:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: C� ��—► 11�C�Ife-� t�f �'� �� ���
Was system pumped as part of the inspection(yes or no): '
If yes,volume pumped:Tgallons--How was quantity pumped determined?
Reason for pumping:
IVE OF SYSTEM
Septic tank,distribution box,soil absorption system
_Single cesspool
Overflow cesspool
_Shared system(yes or no)(if yes,attach previous inspection records,if any)
_hmovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
_Tight tank Attach a copy of the DEP approval
_Other(describe):
Approximate age of all components, to installed Af known)and s94rce of information:
Were sewage odors detected when arriving at the site(yes or no):Xb
I P
Page 7 of 11
OFFICIAL INSPECTION FORM--NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INF RMATION(continued)
Property Address: 16 �" � r
Owner. SC v� c !r�
Date of Inspection: & O -
BU LDING SEWER(locate on site plan
Depth below grade:
ew
Materials of construction: cast iron 40 PVC other(explain):
Distance from private water—supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC T (locate on site plan)
!l
Depth below grade:
Material ofconstruciiotr concrete metal fiberglass_polyethylene
-
-other(explain)-If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of
Dimensions:
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle: '1C
Scum thickness:
Distance from top of scum to top of outlet tee or baffle: /A
Distance from bottom of scum to bottom of outlet tee or baffle: 4; ' .
How were dimensions determined-_:f Q
Comments(on pumping recommendationsy inlet and outlet tee or baffle condition,structural integrity,liquid levels
_pirelated to outlet inv 'dence of 1 etc.):
r
1 r 0-t c,e- it r sib
GREASE TRAP:#ocate on site plan)
Depth below grade:_
Material of construction:—concrete metal fiberglass polyethylene_other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottoms of scum to bottom of outlet tee c baffle:
Date of last pumping
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
Page 8 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFO TION(continued)
Property Address: %,rA'L uJ'�
7d S
Owner. SC�ne e.
Date of Inspection: X
TIGHT or HOLDING TANK:4tank must be pumped at time of inspectionXIocate on site plan)
Depth below grade:
Material of construction: concrete metal fiberglass_polyethylene other(explain):
Dimensions:
Capacity: Gallons
Design Flow: gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: 0
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
I"e Mt or ut of x,etc.): i
PUMP CHAMBER Zate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition ofpump chamber,condition of pumps and appurtenances,etc.):
Page 9 of l l
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM_
PART C
9 SYSTEM INFORMATION(continued)
Property Address:
Owner:he ef-
Date of Inspection•
SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required)
If SAS not located explain why:
leaching pits,number:
leaching chambers,number:
leaching galleries,number:
leaching.trenches,number,length:
leaching fields,number,dimensions: _
overflow cesspool,number:
innovativelalteinative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,
etc.),
� ,e (to F�`t x
CESSPOOLSof must be pumped as of ins ection locate on site plan)
Po PAP 1� P )( P )
Number and configuration:
Depth—top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition ofvegetation,etc.):
PRIVY: &/Ate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
f
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued) .
Property Address:
Owner:
t0-ftoje-
Date of Inspectioni.
: O
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.
I
d
30
Y3 77_6
70
f
Page 11 of l l
OFFICIAL INSPECTION FORM—NOT FOR
STE11�I INSPE TION FORM ASSESSMENTS .
SUBSURFACE SEWAGE DISPOSAL
PART C .
SYSTEM INFORMA ON(continued)
property Address: n,Q�_3'cAJ n
Owner:
Date of Inspection: �--
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water feet
Please indicate(check)all methods used to determine the high ground water elevation:
fans on record-If checked,date of design plan reviewed:
Obtained from system design p
Observed site(abutting property/observation hope wi 150 feet of SAS)
Checked with local Board of Health-explain: �P
Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
ou m describe how you established Me high grom►d ater elution:
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CERTIFICATE OF ANALYSISRECEIVE®Page
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"i
Barnstable County Health Laboratory
MAY 13 2003
Report Prepared For:
Report Dated: 5/1/2003
TOWN OF BARNSTABLE
Order Numbe : G03- 4194A31T•
Elizabeth P.Andac
94 Millway
Bamstable MA 02630
Laboratory ED#: 0319495-01 Description: Water-Drinking Water
Sample#: 19495 Sampling Location: 916 Santuit-Newtown Rd.,Marstons Mills Collected 4/24/2003
Collected by: Elizabeth An Received 4/24/2003
Routine
ITEM RESULT UNITS MCL Method# Tested
LAB: IC Lab
Nitrates 5.2 mg/L 10 EPA 300.0 4/24/2003
LAB: Metals
Copper 0.7 mg/L 1.3 SM 3111B 4/25/2003
Iron <0.1 mg/L 0.3 SM 3111B 4/25/2003
Sodium 18 mg/L 20 SM 311113 4/25/2003
LAB: Microbiology
Total Coliform Absent P/A Absent 309 4/24/2003
LAB: Physical Chemistry
Conductance 154 umohs/cm EPA 120.1 4/24/2003
pH 6.4 pH-units EPA 150.1 4/24/2003
Note: Sample has higher than average levels of Nitrates.Monitoring is recommended(2-3 times per year)to establish any upward
trends.'
Approved By: Vt76 r �' ,5 L&
(Lab Director)
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Superior Court House, PO.Box 427, Barnstable, MA 02630 Ph: 508-375-6605
i `OE nAq
=` CERTIFICATE OF ANALYS S RECEwE�age-
�J �� .n'c :a. m
fi -' ' ` Barnstable County Health Laboratory
-:H-,sY MAY 15 2003
Report Prepared For:
Report Dated: OS/13/2003
Order Num e__TowN ; 9�49 ABLE
HC DtPT.
Elizabeth P. Andac
94 Millway
Barnstable, MA 02630
Laboratory ID#: 0319495-01 Description: Water-Drinking Water
Sample#: 19495 0801 802 803 Sampling Location: 916 Santuit-Newtown Rd.,Marstons Mills Collected: 04/24/2003
Collected by: E Andac Received: 04/24/2003
i
EPA 524.2- Volatile Organics by GC/MS
ITEM RESULT UNITS MDL MCL Method# Tested
LAB. GUMS
1,1,1,2-Tetrachloroethane BRL ug/L 0.5 EPA 524.2 05/03/2003
1,1,1-Trichloroethane - BRL, ug/L 0.5 200 EPA 524.2 05/03/2003
1,1,2,2-Tetrachloroethane BRL ug/L-, 0.5 -"' EPA 524:2 " 05/03/2003------
1,1,2-Trich10r4jethane BRL, ug/L 0.5 5.0 EPA 524.2 05/03/2003
1j-Dich16'r'6ethane $RL ug/L• 0.5 EPA 524.2 05/03/2003
1';1'=Dichloroethene�`= BRL- ug/L- 0.5 7.0 EPA 524.2 05/03/2003
IJ-Dichloropropelle BRL ug/L 0.5 EPA 524.2 05/03/2003
1,2,3-Trichlorobenzene BRL ug/L 0.5 EPA 524.2 05/03/2003
1,2,3-Trichloropropane BRL ug/L 0.5 EPA 524.2 05/03/2003
1,2,4-Trichlorobenzene BRL ug/L 0.5 70 EPA 524.2 05/03/2003
1,2,4-Trimethylbenzene BRL ug/L 0.5 EPA 524.2 05/03/2003
1,2-Dibromo-3-chloropropan BRL ug/L 0.5 EPA 524.2 05/03/2003
1,2-Dibromoethane (EDB) BRL ug/L 0.5 EPA 524.2 05/03/2003
1,2-Dichlorobenzene BRL ug/L 0.5 600 EPA 524.2 05/03/2003
1,2-Dichloroethane BRL ug/L 0.5 5.0 EPA 524.2 05/03/2003
1,2-Dichloropropane BRL ug/L 0.5 EPA 524.2 05/03/2003
1,3,5-Trimethylbenzene BRL ug/L 0.5 EPA 524.2 05/03/2003
1,3-Dichlorobenzene BRL ug/L 0.5 EPA 524.2 05/03/2003
1,3-Dichloropropane BRL ug/L 0..5 EPA 524.2 05/03/2003
r,4-Dichlorobenzene BRL ug/L o.5 5.0 EPA 524.2 05/03/2003
2;2-Dicliloroprapa•ne BRL L 0.5 EPA 524.2 05/03/2003 E
s -
2=.Cllorotoluene's� •BRL Ug�1 0.5 EPA 524.2 05/03/2003 7
tom,,; .M,t«;t•;;, t
_VC hNf6t61 de 66 4 „ 5 -BRL ug/L 0.5 EPA 524.2 05/03/2003
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Superior Court House, PO. Box 427, Barnstable, MA 02630 Ph: 508-375-6605
�oE Hggy._
Page. z
CERTIFICATE OF ANALYSIS
M,
Barnstable County Health Laboratory
Report Prepared For: Report Dated: 05/13/2003
Order Number: G0319495
Elizabeth P.Andac
94 Millway
Barnstable, MA 02630
Laboratory ID#: 0319495-01 Description: Water-Drinking Water
Sample#: 19495 0801 802 803 Sampling Location: 916 Santuit-Newtown Rd.,Marstons Mills Collected: 04/24/2003
Collected by: E Andac Received: 04/24/2003
Benzene BRL ug/L 0.5 5.0 EPA 524.2 05/03/2003
Bromobenzene BRL ug/L 0.5 EPA 524.2 05/03/2003
Bromochloromethane BRL ug/L 0.5 EPA 524.2 05/03/2003
Bromodichloromethane BRL ug/L 0.5 EPA 524.2 05/03/2003
Bromoform BRL ug/L 0.5 EPA 524.2 05/03/2003
Bromomethane BRL ug/L 0.5 EPA 524.2 05/03/2003
Carbon tetrachloride BRL ug/L 0.5 5.0 EPA 524.2 05/03/2003
Chlorobenzene BRL ug/L 0.5 100 EPA 524.2 05/03/2003
Chloroethane BRL ug/L 0.5 EPA 524.2 05/03/2003
Chloroform 1 ug/L 0.5 EPA 524.2 05/03/2003
Chloromethane BRL ug/L 0.5 EPA 524.2 05/03/2003
cis-1,2-Dichloroethene BRL ug/L .0.5 70 EPA 524.2 05/03/2003
cis-1,3-Dichloropropene BRL ug/L 0.5 EPA 524.2 05/03/2003
Dibromochloromethane BRL ug/L 0.5 EPA 524.2 05/03/2003
Dibromomethane BRL ug/L 0.5 EPA 524.2 05/03/2003
Dichlo rod ifluo romethane BRL ug/L 0.5 EPA 524.2 05/03/2003
- Ethylbenzene BRL ug/L 0.5 700 EPA 524.2 05/03/2003
Hexachlorobutadiene BRL ug/L 0.5 EPA 524.2 05/03/2003
Isopropylbenzene BRL ug/L 0.5 EPA 524.2 05/03/2003
Methyl-tert-butyl ether BRL ug/L 0.5 EPA 524.2 05/03/2003
Methylene chloride BRL ug/L 0.5 5.0 EPA 524.2 05/03/2003
n-Butylbenzene BRL ug/L 0.5 EPA 524.2 05/03/2003
n-Propylbenzene BRL ug/L 0.5 EPA 524.2 05/03/2003
Naphthalene BRL ug/L 0.5 EPA 524.2 05/03/2003
p-Isopropyltoluene BRL ug/L 0.5 EPA 524.2 05/03/2003
sec-Butylbenzene BRL ug/L 0.5 EPA 524.2 05/03/2003
Styrene BRL ug/L 0.5 100 EPA 524.2 05/03/2003
Superior Court House, PO. Box 427, Barnstable, MA 02630 Ph: 508-375-6605
%OF NAR,.
'? CERTIFICATE OF ANALYSIS Page: 3
Barnstable County Health Laboratory
Report Prepared For:
Report Dated: 05/13/2003
Order Number: G0319495
Elizabeth P.Andac
94 Millway
Barnstable, MA 02630
Laboratory ID#: 0319495-01 Description: Water-Drinking Water
Sample# 19495 0801 802 803 Sampling Location: 916 Santuit-Newtown Rd.,Marstons Mills Collected: 04/24/2003
Collected by: E Andac Received: 04/24/2003
tert-Butylbenzene BRL ug/L 0.5 EPA 524.2 05/03/2003
Tetrachloroethene BRL ug/L 0.5 5.0 EPA 524.2 05/03/2003
Toluene BRL ug/L 0.5 1000 EPA 524.2 05/03/2003
Total xylenes BRL ug/L 0.5 10000 EPA 524.2 05/03/2003
trans-1,2-Dichloroethene BRL ug/L 0.5 100 EPA 524.2 05/03/2003
trans-1,3-Dichloropropene BRL ug/L 0.5 EPA 524.2 05/03/2003
Trichloroethene BRL ug/L 0.5 5.0 EPA 524.2 05/03/2003
Trichlorofluoromethane BRL ug/L 0.5 EPA 524.2 05/03/2003
Vinyl chloride BRL ug/L 0.5 2.0 EPA 524.2 05/03/2003
Routine
ITEM RESULT UNITS MDL MCL Method# Tested
LAB: IC Lab
Nitrates 5.2 mg/L 0.1 to EPA 300.0 04/24/2003
LAB:Metals
Copper 0.7 mg/L 0.1 1.3 SM 3111B 04/25/2003
Iron <0,1 mg/L 0.1 0.3 SM 3111B 04/25/2003
sodium 18 mg/L 1.0 20 SM 3111B 04/25/2003
LAB: Microbiology
Total Coliform Absent P/A 0 Absent 309 04/24/2003
LAB: Physical Chemistry
Conductance 154 umohs/cm 1 EPA 120.1 04/24/2003
pH 6,4 pH-units 0.1 EPA 150.1 04/24/2003
Superior Court House, PO. Box 427, Barnstable, MA 02630 Ph: 508-375-6605
i
f�`pF Hgjt��
Page: 4
CERTIFICATE OF ANALYSIS g
`3yrs�c�usw� ' Barnstable County Health Laboratory
Report Prepared For: Report Dated: 05/13/2003
Order Number: G0319495
Elizabeth P. Andac
94 Millway
Barnstable, MA 02630
Laboratory ID#: 0319495-01 Description: Water-Drinking Water
Sample ih 19495 0801 802 803 Sampling Location: 916 Santuit-Newtown Rd.,Marstons Mills Collected: 04/24/2003
Collected by: E Andac Received: 04/24/2003
Note: Sample has higher than average levels of Nitrates.Monitoring is recommended(2-3 times per year)to establish any upwar
trends.
Approved By: y'1 GS I3 3
(Lab Director)
Superior Court House, PO. Box 427, Barnstable, MA 02630 Ph:508-375-6605
V
V
Date: t ``
TOXIC AND HAZARDOUS MATERIALS R IStRATION FORM'. :
NAMEOFBUSINESS: 1`c� �l
BUSINESS LOCATION: l (lLM!&217J1, y"
MAILINGADDRESS: ?, Aft, ,'--- kS Mail To:
TELEPHONE NUMBER: C GC)&) Board of Health
Town of Barnstable
CONTACTPERSON: o P.O. Box 534
EMERGENCY CONTACT TELEPHONE NUMBER: Hyannis, MA 02601
TYPE OF BUSINESS: ��o�-t Oy S i oj E &tVaLnf s,� C—L_
Does your firm store any of the toxic or hazardous materials Iisted below, either for sale or for you own
use? YES NO K'
This form must be returned to the Board of Health regardless of a yes or no answer. Use the enclosed
envelope for your convenience.
If you answered YES above, please indicate if the materials are stored at a site other than your mailing
address:
ADDRESS:
TELEPHONE:
LIST OF TOXIC AND HAZARDOUS MATERIALS
The Board of Health has determined that the following products exhibit toxic or hazardous character-
istics and must be registered regardless of volume. Please estimate the quantity beside the product that
you store. NOTE: LIST IN TOTAL LIQUID VOLUME OR POUNDS.
Quantity Quantity
Antifreeze(for gasoline or coolant systems) Drain cleaners
NEW USED Cesspool cleaners
Automatic transmission fluid Disinfectants
Engine and radiator flushes Road Salt (Halite)
Hydraulic fluid (including brake fluid) Refrigerants
Motor oils Pesticides
NEW USED (insecticides, herbicides, rodenticides)
Gasoline, Jet Fuel Photochemicals (Fixers)
Diesel fuel, kerosene, #2 heating oil NEW USED
Other petroleum products: grease, Photochemicals (Developer)
lubricants, gear oil NEW USED
Degreasers for engines and metal Printing ink
Degreasers for driveways & garages Wood preservatives (creosote)
Battery acid (electrolyte) Swimming pool chlorine
Rustproofers Lye or caustic soda
Car wash detergents Jewelry cleaners
Car waxes and polishes Leather dyes
Asphalt & roofing tar Fertilizers
Paints, varnishes, stains, dyes PCB's
Lacquer thinners Other chlorinated hydrocarbons,
NEW USED (inc. carbon tetrachloride)
Paint & varnish removers, deglossers Any other products with "poison" labels
Paint brush cleaners (including chloroform, formaldehyde,
Floor & furniture strippers hydrochloric acid, other acids)
Metal polishes
Laundry soil & stain removers Other products not listed which you feel
(including bleach) may be toxic or hazardous (please list):
Spot removers & cleaning fluids
(dry cleaners)
Other cleaning solvents
Bug and tar removers
WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS
;*
TOWN OF B.ARNSTABLE
LOCATION SEWAGE
VILLAGE$WZdAebid ASSESSOR'S MAP & LOT
INSTALLER'S NAME dz PHONE NO.a&-
SEPC TANK CAPACITY
bX
3 LEACHING FACILITY:(type) .(size)
NO. OF BEDROOMS PRIVATE WELL OR Fig
BUILDER OR OWNER � 1
DATE PERMIT ISSUED: �P
DATE .COMPLIANCE ISSUED-.,
VARIANCE GRANTED: Mm. No
cL
TOWN OF B.ARNSTABLEIT-
C G
LOCATION ..- SEWAGE
VILLAGE ASSESSOR'S MAP 6z LOT
INSTALLER'S NAME PHONE NO.aet
a
SEI'7.IC TANK CAPACITY 'l�
LEACHINGFACILITY:(type) (size)
NO. OF BEDROOMS q PRIVATE WELL OR
.aM 3
BUILDER OR OWNER °
DATE PERMIT ISSUED: '?
DATE .COMPLIANCE ISSUED:.
.r
K
VARIANCE GRANTED: Xft No
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F �bIA i
1® Ll
r
AISSUSSOR'S �,`AP —1Z QI-7 - 0 1 7N
No.. Fmc....
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...........................................OF.......................................................---------------------------------
Appliratiou for Elispasal lVarks Tonstrartion Vamit
Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal
System at:
q4-
...... .....................
---PZ, . ......... .................................................................................
i; . or Lot No...................... ............
Owner
Addres�.'''........................................ --- ...... . .............
.............
Installer Address
PQ 4/O ,0o0
U
C� Type of Building Size Lot...........................Dwelling L Bedrooms_______________________________________Expansion/..................................Expansion Sq. feet
�No. of Bedro Attic Garbage Grinder ( )
'-1
P4 Other—Type of Building ............................ No. of persons............................ Showers Cafeteria ( )
P4Other fixtures ............................................................. ....................................................................................
Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
04 Septic Tank—Liquid capacity,/SP.�allons Length................ Width.........._..... Diameter-_.---__--____-_ Depth_....__.....___.
Disposal Trench—N Width--------------------- Total Length............_...._. Total leaching area....................sq. f t.
Seepage Pit No--------%i -------- lameter....(Q--- -------- Depth below inlet...6............. Total leaching area..................sq. ft.
Z Other Distribution box (-4-) Dosing tank ( ) - .4,
Percolation Test Results Performed by.......................................................................... Date... -------
Test Pit No. 1________________minutes per inch Depth of Test Pit-__-_------__-____-- Depth to ground water-.--_.---_--
----
Test Pit No. 2................minutes per inch Depth of Test Pit___.._.......___.__. Depth to ground water!e��Ali
- ---------------------*---- -------------*-------------------*------- ---------------
-----------
0 Description of .................................................................................................................
W
U ........................................................................................................................................................................................................
------------------- ------------------------------------------------------------------------------------------------------- -----------------------a---------------_4—--------------------------
U Na ure of RejjW*rs OVAlterations r we Ans h 10&X .....................
Ic;
4- .......... ... y
. .. ... .........
90 P- ...............................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of'T'L7, of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been is ued b oard d D the of. eal.th.
4' . .....
Signed. .... ..... .. ...... . . ........................... ........................Date
t-e........8.4
Application Approved By.................. ..... ......................... ..........
(— Date
Application Disapproved for the following reasons:..............................................................................................................
.........................................................................................................................................................................................................
Date
Permit No...... Issued....................... -2— -:s 6 — S-
..........................Z.................
Date
7� "7
No�,'
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................................O F.......................................--------------------....................._......---
Appliratiaan for M-4posal Marks Tonstrurtiaan Frrnti#
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage-Disposal
System at:
*d'4...........................................................................................
Location-Address / or Lot No.
rt"n- ifs ,
= - ---•-•----•--•-•-------------••---•----••-•----• --•--•-------------•---•-•---•--=•------•-•---•-•---.......-•---•----•--•----••=••--•--•-...--•---
• Owner
n
/ Installer Address
Type of Building Size Lot----------------------------
Sq. feet
Dwellings!No. of Bedrooms.. .........................................Expansion Attic ( ) Garbage Grinder ( )
pa-, Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
QI Other fixtures ................................. . ----------
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
9 Septic Tank—Liquid capacity..._`... gallons Length................ Width................ Diameter---------------- Depth--•_--_.-___---.
Disposal Trench—N .................... Width- ___.:...._._.... Total Length.............
..`_...f_._..... Total leaching area....................sq. ft.
Seepage Pit No........ �..._._.. Diameter.................... Depth below inlet._._.... .......... Total leaching area..................sq. tt.
Z Other Distribution box (Y ) Dosing tankr . a
'~ Percolation Test Results Performed by.......................................................................... Date---}--
........ ......... .........
Test Pit No. 1................mmutes per inch Depth of Test Pit.................... Depth to ground water-------------''_-----L.
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water. 'L........_...`f �
•---•-•--• '1--••--•---------•------•----'"------------------•---...................•-•--•-----••••-•--•-•---•-------•-...----------•-----•--....•---•-••.
D Description of Soil._—
" '"`='v
---------;•-•---•---•-•----•-•-•---------------•---•----------------------------------------•--•-•--••••---------
U Nature of Repairs or. Alterations—Answer when.applicable___ '*P - �>A�.•.*�
,r r JL
(......._.. c...fi.cCrj -t ............................t� i�........ i i--
� rr
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of'T'IE; 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of.health.
Signed. -'..---r..... .
Date
Application Approved By.....................................................::.................... .
Date
Application Disapproved for the following reasons:.......................•---•---•------------------------------------------------•------••-••------••---••--•--
...........................................................•.._..••---••-----•-------...--•--•-•--•----•-----•••----•----------------------••--------•----•••-----------••--------=-••......---------•-
Date
a
PermitNo..... -------------------------------------------- Issued.........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
f. ;.t_.
.......... .....:C-::7.2..t.............OF........• r...............5. .:fir-..:.... '..........................................
Trrtifiratr of Taantplinnre
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( }
Installer
at
has been installed in accordance with the provisions of TITIE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit. No.. /_::__j9'_�,.............. da.ted....._�_r=__�._�-......�5:'............
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT YHE
SYSTEM WILL FUNCTION SATISFACTORY. t
DATE.................... .^. -.G.:... ............................ Inspector.....-- ..................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
f ._ . _-
......../.f�.:. .OF...... :.:.: ._�xrl ,>�
�io��oao�ii� �ark� �oan�#rioan rrnti� •
Permission is hereby granted_.....;;=:_._._ '_1 J(rw ::...................
to Construct ( ) or Repair_�-<7 an Individual Sewage Disposal System
atNo.........7;�1. _ ............................. _._--.. _ _ .._ .......................................................
Street
as shown on the application for Disposal Works Construction Permit No. .:_.¢'._c-___ Dated.-_--'...........:. .....%.....:.....
DATE- td t/ Board of Health
.... - ; =-- --••---•--f_'.,E.................................
FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS