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HomeMy WebLinkAbout0026 CARLSON LANE - Health 26 Carlson Lane West Barnstable .A= 1.33-062 o TOWN OF BARNSTABLE LOCATION ,,?� ( ;Cil'�S�h Lane. SEWAGE # i VILLAGE W65i ASSESSOR'S MAP & LOTi ��D INSTALLER'S NAME & PHONE NO. J3_ r I L SEPTIC TANK CAPACITY I 0 6 LEACHING FACILITY:(type)A (size) (Xj NO. OF BEDROOMS _PR,LIVATTE WELL OR PUBLIC WATER rl /&6,a BUILDER OR OWNER DATE PERMIT ISSUED: J-aQ- C S DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No y Ak 53 � Ac, 5b i iAD i p ' 3 D 4 113 Commonwealth of Massachusetts 133 -�� 1 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments tr ° °M 26 Carlson Ln Property Address Peter Marshall Stonecape Trust ' Owner Owner's Name information is required for every W Barnstable Ma 02668 7/2/18 ... page, City/Town State Zip Code Date of Inspection `J Inspection results must be submitted on this form. Inspection forms may not be altered in any comp leteness. Please see checklist at the end of the form. Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: key to move your cursor-do not Michael DiBuono use the return Name of Inspector Y DiBuono Sewer and Drain r� Company Name 35 Content Ln Company Address Cotuit MA 02635 City/Town State Zip Code 508-364-9587 SI 13522 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: - ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by.the Local Approving Authority 7/2/18 nspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage -Disposal System Page 1 of 17 p Y 9 W • Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ° 26 Carlson Ln M Property Address Peter Marshall Stonecape Trust Owner Owner's Name information is required for every W Barnstable Ma 02668 7/2/18 page. CitylTown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: System contains a 1500 gallon H2O septic tank. As well as two 1,000 Gallon H2O leach pits in stone. B) System Conditionally Passes: ❑ One or more system components 2s described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts ,W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 26 Carlson Ln Property Address Peter Marshall Stonecape Trust Owner Owner's Name information is required for every W Barnstable Ma 02668 7/2/18 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official'lnspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts WTitle 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 26 Carlson Ln Property Address Peter Marshall Stonecape Trust Owner Owner's Name information is W required for every Barnstable Ma 02668 7/2/18 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A co of the analysis must 99 PY Y be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool El ® 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 Y2 day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments <° 26 Carlson Ln M Property Address Peter Marshall Stonecape Trust Owner Owner's Name information is required for every W Barnstable Ma 02668 7/2/18 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form r.. _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 26 Carlson Ln Property Address Peter Marshall Stonecape Trust Owner Owner's Name information is W Barnstable Ma 02668 7/2/18 required for every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 26 Carlson Ln M Property Address Peter Marshall Stonecape Trust Owner Owner's Name information is required for every W Barnstable Ma 02668 7/2/18 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d Well 9 ( Y 9 (gp ))� Detail: Sump pump? ❑ Yes ❑ No Last date of occupancy: Date Commercial/industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No MIndustrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form ' Y Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 26 Carlson Ln Property Address Peter Marshall Stonecape Trust Owner Owner's Name information is W Barnstable Ma 02668 7/2/18 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Pumped 7/2/18 Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments /4M 26 Carlson Ln Property Address Peter Marshall Stonecape Trust Owner Owner's Name information is required for every W Barnstable Ma 02668 7/2/18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Original to home. Tank was replaced after cave in. Replaced with H2O 1500 Gallon Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ® cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 14' feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) 1500 If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 26 Carlson Ln Property Address Peter Marshall Stonecape Trust Owner Owner's Name information is W Barnstable Ma 02668 7/2/18 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 24" Scum thickness 3" Distance from top of scum to top of outlet tee or baffle 42" Distance from bottom of scum to bottom of outlet tee or baffle " Sludge stick How were dimensions determined? Tape Measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Grease Trap (locate on site plan): Depth below grade: feet 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 bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 26 Carlson Ln M Property Address Peter Marshall Stonecape Trust Owner Owner's Name information is required for every W Barnstable Ma 02668 7/2/18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): i *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 26 Carlson Ln Property Address Peter Marshall Stonecape Trust Owner Owner's Name information is required for every W Barnstable Ma 02668 7/2/18 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert NA 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.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 26 Carlson Ln Property Address Peter Marshall Stonecape Trust Owner Owner's Name information is required for every W Barnstable Ma 02668 7/2/18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 2 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): No break out no ponding Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 26 Carlson Ln Property Address Peter Marshall Stonecape Trust Owner Owner's Name information is required for every W Barnstable Ma 02668 7/2/18 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): I l5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 26 Carlson Ln Property Address Peter Marshall Stonecape Trust Owner Owner's Name information is required for every W Barnstable Ma 02668 7/2/18 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately t5ins-3113 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 26 Carlson Ln Property Address Peter Marshall Stonecape Trust Owner Owner's Name information is re W Barnstable Ma 02668 7/2/18 required for every G page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 15+feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: Test hole data on plan Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 7/2/2018 Assessing As-Built Cards l� TOWN OF BARNSTABLE LOCATION (;Cti 15cn Lane. SEWAGE VILLAGE�F�� ?j-n5 1�I F ASSESSOR'S MAP& I-OT/ Der INSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITY j �.: __ LEACHING FACILITY:(type), P,-A0 lcoo size.) i I NO. OF BEDROOMS PRIVA/TE�W�ELL OR PUBLIC ':✓ATER 1, BUILDER OR OWNERTn�r/X DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: ' VARIANCE GRANTED: Yes No_� AA:; As:� A c 5b , A D 1: AC : &C> SA sb 2 ' pg = 3SL ,q 8 of � ySt I� f http://www.townofbarnstable.us/Assessing/HMdisplay.asp?mappar=133062&seq=1 1/2 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 26 Carlson Ln Property Address Peter Marshall Stonecape Trust Owner Owner's Name information is required for every W Barnstable Ma 02668 7/2/18 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ❑ Inspection Summary: A, B, C, D, or E checked ❑ Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ❑ System Information— Estimated depth to high groundwater ❑ Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 ASSESSORS MAP NO,_Y ✓�, PARCEL N0- 11 41 No.. .......__... Fps............................ .. THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH TOWN OF BARNSTABLE Xpli iratuan for Bivi-pwial Workii Towitrnrtion Vann# Application is hereby made for a Permit to Construct (X ) or Repair ( ) an Individual Sewage Disposal System at ........ �'.6..C.Arr�I.,SQI`J..Tom. ----•-••----•-•------ --------- '--#-�..C7 ISQI�-�PtE------•----•-- Location-Address or Lot No. ----•--------•--r'W...T?D rrtAl?9 AL ---------------------•----------------- -------- -373. ..POCA•SSF7 --A. 2559...................... Owner Address JJ DRISCOLL 381 OLD FALMOUTH RD. MARSTON MILLS, MA Installer ���Y Address d Type of Building 3� Size Lot---43 832 Sq. feet Dwelling— No. of Bedrooms._.,K_Aj------------------------------Expansion Attic ( ) Garbage Grinder (NOl aOther—Type of Building ---------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( ) dOther fixtures --------------------------------- ----------------------------------------------------- ----------------------------------------------•-•---.-------- W Design Flow.......55........------------------------gallons per person per day. Total daily flow-----330...............................gallons. WSeptic Tank—Liquid capacity__1500galIons Length_?_0'_6"_ Width----- Diameter_------------- Depth-----i.'_7..". x Disposal Trench—No. .................... Width-----_----_------_- Total Length---------_--------- Total leaching area--------------------sq. ft. Seepage Pit No----------1---------- Diameter---1_G'.........- Depth below inlet-------4.1........ Total leaching area...... 1.0.....sq. ft. Z Other Distribution box (X ) Dosing tank ( ) aPercolation Test Results Performed by......Ro d.nal ...S.....I;a _i.i_LaC................ Date...D-.0...... �....1.9.� ..a Test Pit No. 1.....2---------minutes per inch Depth of Test Pit------_ ------- Depth to ground water....raprl-&........ fX4 Test Pit No. 2................minutes per inch Depth of Test Pit.-----. -__-_-_--_- Depth to ground water........................ P4 -------------•----------•-------------•----•-----------••--•---•-------•------•••-----------._............------------------------•-•--•----------...._...... Description of Soil..... -!_-2-...... pso -l---&.--s1z' 2-'•-6.-1.!---tight•-s.iltl�_._sand-,-___6 .�!- v 1.2, medium --sand some...szlt-� ?2 -• 1.6'_.•Medium -sand- ro. . -----...--- W ..................... .... groundwater-------------------------------------------------- U Nature of Repairs or Alterations—Answer when applicable------------------.------....................................................................... --------------------------------•--•-----------------------•------------------------------------------------------------------------------------.....-----------------------------------•-----••........ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The rsigned further agrees not to place the system in operation until a Certificate of Compli ce e n issued y t b a d h th. Signed ------ . Y 11 Application.Approved B ----------- ' ------ ----------- --- -------------------------------- Application `--- -------------- Dare Disapproved for the following reasons: ---------------------------------------------- ------ --------------------------------------------------------------------------- ---- --------*--------------------------- .. : ......._........ - - ---------------------------------------�- ---------------------------------------- Permit No. .... -................ ................ Issued ... ----�- Due THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliration for Diti-Vitiittl Wor1w Towitrnr#illit rFrnfit Application,is hereby made for a Permit to Construct (X ) or Repair ( ) an Individual Sewage Disposal System at: .................•-----26 C.ARIO. N--VA�--------------------.......------------ -------- Location-Address f 9 or Lot No. --.....-•-•---•-•---r n •..?...�sr�rs---------------------------------•--•-- ---------P.......3738•hoc s> r-=--.rt�--02559.-------•-•-•-----•--- Owner Address W JJ DRISCOLL 381 OLD FAIbULI H RD. M4=ON MILLS, MA . ---•-----------------•-•----••--•---•---•----•--------•-•---•-••--. •--------------------------------------------•------------------t------------------------.------ Installer j ,� 3/pOICA Address I��„(_J 43 832 S Q Type of Building Size Lot.......................... q. feet U Dwelling—No. of Bedrooms._/-_JY------------------------------Expansion Attic ( ) Garbage Grinder a`q Other—T e of Building _---- No. of persons............................ Showers YP g ----------------------- P ( ) — Cafeteria ( ) dOther fixtures -------------------------------------------------------------------------------------- -----------------•------------------------------------------- Design Flow-------55_____________________________)._gallons per person per day. Total daily flow_.1...330 gallons. ---- --------------------- ------ J WSeptic Tank—Liquid capacity_-1500galIons Length_ Q___6_"_ Width-----5___ Diameter______________ Depth...... x Disposal Trench—No. .................... Width-------------------- Total Length.................... Total,`leaching area.........._.........sq. ft. Seepage Pit No..........I.......... Diameter._.0.......__.__ Depth below inlet....... ......... Total leaching area.._-_r__!=f?.....sq. ft. z Other Distribution box (X ) Dosing tank ( ) aPercolation Test Results Performed by------- on_a_1.d----tl.,-...17,a�111.7_-s................... Date..e.C_�._.. Test Pit No. 1.....2---------minutes per inch Depth of Test Pit_____:!_ !.___--- Depth to.gr:ound water....nran..n-........ f1 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ P+ ----•------------------------------•-----•----•----------.....-•--------••-•-•-••---------•-•-----•.•• --..--------••------• ....... ....... D Description of Soil....01_-2.'___topsoil & subsoil 2 ' -6 . 11! tight silty sand , 6. 5 ' — x 12 ' medium sand some silt , 121 16' medium sand , no -- --------- ---•••. -----_... ••------ -----•-- -•-•-•-• ------...------•--• ---- • --•••--- •---.-•--•- W r roundiTater ------------------------------------------------------------------------------------------------------------------------------------------------•-•••----•-- U Nature of Repairs or Alterations—Answer when applicable............................................................................................... ---------------------------------------------•-------...----------•-----------------•---------------------------------------------------------------------------------------------------••-••--•-.--•--- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The ersigned further agrees not to place the system in operation until a Certificate of Compli ce s een issued y t �e board of health. Signed = — — `-( uf-.l t. ... '> �� \J ..- �4...... 65 Application.Approved BY ..... -------- . ..... ..�....- ......-_................................._ ......--.........--_ Date Application Disapproved for the following reasons- -- -------------------------------------------i -------------------------------...........----.----------------------------- --------------------------------------------------------------- ........................................ Permit No. ..............�`'Y-. ..T.-.-. Issued _ F~------?----6-- -� Dale THE COMMONWEALTH OF MASSACHUSETTS � l BOARD OF HEALTH i ! T(O��ttWN OF BARNSTABLE V Elfifi ate 6f Tvmy i2 nrji THIS IS TO� CQ RAY T)A e Individual Sewage Disposal System constructed ( �or Repaired ( ) • . -- - ----- ................ ------- - - ----- ----------- .....--------- -- Insrdler at ....._......��a . �- -��'----�� - `l�1� -- -� --- ---- ..-�J--�:.'---------------------------------f�✓.- ram. has been installed in accordance with the provisions of TITLE/'5�' o :heStaw_E�aylronmental Code as described in the application for Disposal Works Construction Permit No. 7_---.---------`.- ...._ -_ dated nF`"�1.-�...��-,�j THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SA1TJISFACTOY-.- cDATE.. .. Inspec rT2!" -----------1--�--/---L- - --- - :.— THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH L' �� TOWN OF BARNSTABLE No............ FEE ....�.. Dispuml _ nrkii Tunitrudion rrrntit Permission is hereby granted. ................................... ...G......----•-------------------•-------...-----•----------......•.... to Construe (4___�or Re air ( ) an Indivitl al Sewage Disposal System at No........ ---•. ..... .��rl'� �� r�lt.._._.. — rr� ............ Street 4;7 as shown on the application for Disposal Works Constructio e it � �.___.�� � � Board of Health DATE.................................................------- ................. FORM 36508 H0819S A WARREN.INC..PUBLISHERS I d FEB 16 '95 09:32 DESMOND WELL DRILL. P. 1 ENVIROTECH LAI3ORA TORIES, INC. MA Cert, No.; M-MA 063 449 Rcc. 130 - Sandwich, NIA 02563 (508)888-6460 - 1-800-339.6460 FAX(508)888.6446 CLIENT: Dodderidge Cnstruotion ADDRESS: 55 Cedar Land Rd LOCATION: Lot 7 Carlson Lane Orleans, MA 0253 # 26 W. Barnstable, MA SAMPLE DATE: 2/1/95 COLLECTED BY: DWD TIME; 4 PM DATE RECEIVED: 2/1/95 : JOB TYPE: Nev Well SAMPLE I.D. 726 WELL DE?m: 66/40, t RESULTS OF ANALYSIS: Parameters Units Recammended Limit Result Coliform bacteria/100m1 (MF Method) 0 pH 0 x Conductance PH units 6.0-8.5 6.08 Sodium . mhos/cam 500 104 Nitrate-N mg/L 28.0 8.8 Iron /L 10.0 0.28 Manganese mg/L 0.05 0.42 0.042 Volatile organics ug/L (EPA601/602) see attached report NONE DETECTED corvTS: Iron level is not a health hazar-d. yes NO 70{X WATER IS SUITABLE FOR DRINKING PURPOSES FOR PARAMETERS TESTED. Date c; Ro ld J. ari Laboratory Director LT = Less Than ' 1t 1 ; t w r . - p,..... .._, P.2 i r GROUNDWATER ANALYTICAL EPA METHODS 501 and 602 Volatile organics (CC/P!ID/ELCO) Field ID: 726 Lab ID: 99:01-0I Project: Dodderidge/Carlson Lane Batch ID: V03-03404 4 Client: Envirotech Sampled: 0g-02-95 Cont/Prsv: 40mL VOA Vial/HC1 Cool Received; 02-03-95 Matrix: Aqueous Analyzed: 02-04-95 PARAMETER CONCENTRATION REPORTING LIMIT ' (u9/L) (ug/L) + Dichlorodifluoromethane 5 Chloromethane BRLBRL 5 "Vinyl Chloride BRL 5 Bromomethane BRL 5 Chloroethane BRL g Trichlorofluoromethane BRL I 41-Dichloroethene BRL I - Methylene Chloride BRRL 1 trans-1,2-Dichloroethene 1 1,1-Dichloroethane BRL I cis-1,2-Dichloroethene * 1 ChloroformBRL BRL 1 { 1,1,1-Trichloroethane BRL I Carbon Tetrachloride BRL I Benzene I 1,2-Dichloroethane BRL 1 Trichloroethene BRL I 1,2-Dichloropropans 1 Bromodichloromethane BRL BRL 1 2-Chloroethyyl Vinyl Ether BRL 5 cis-1,3-Dichloropropene BRL I Toluene BRL trans-1,3-Dichloropropene BRL 1 1,1,2-Trichloroethane BRL 1 Tetrachloroethene I BR Dibromochloroinethane BRL 1 Chlorobenzene, 1 Ethylbenzene BRL 1 meta-and Para-Xylene * BRL 1 ortho-Xylene * BRL I Bromoform BRL 1 1,1,2;2-Tetrachloroethane BRL 1,3-Dichlorobenzene BRL 1 1,4-Dichlorobenzene BRL 1 1,2-Dichlorobenzene BRL I QC SURROGATE COMPOUND SPIKED MEASURED RECOVERY QC LIMITS i a,a,a-Trifluorotoluene 30 31 105 % 87 - 113 % 1,2-Dichloroethane-d4 30 33 1I0 I 83 - 117 BRL Below Reporting limit. * Non-target compound. Method References: Method 601 - Purgeable f Halocarborts and Method 602 - P,urgeable Aromatics, 40 C.F.R. 136, Appendix A (1986), i * * I N V O I C E ---------------- DESMOND WELL DRILLING INC. INVOICE NO. : 02839 5 RAYBER ROAD P.O. BOX 2783 CUSTOMER N0, :0383 ORLEANS, MA 02653 DATE : 02/03/95 ( 508) 240-1000 SOLD TO: DODDERIDGE CONSTRUCTION P.O. BOX 431 EAST ORLEANS, MA 02643 DUE ON RECEIPT QUANTITY DESCRIPTION PRICE AMOUNT JANUARY 31 & FEBRUARY 1 , 1995---_•---------_-�---_��--���---_�- JOB LOCATION: LOT 7 CARLSON LANE W. BARNSTABLE CUT IN & MADE ACCESS FOR DRILL RIG. DRILLED TEST HOLE & INSTALLED WELL WITH 3 ' STAINLESS STEEL WELL SCREEN. PUMPED OFF AND FLOW WAS 5GPM WITH 30 FEET OF DRAWDOWN. PULLED WELL & REDRILLED AND ADDED AN ADDITIONAL 4' OF STAINLESS STEEL WELL SCREEN. PUMPED OFF WELL AND FLOW WAS 20 GPM WITH 2 FEET DRAWDOWN . SAMPLES TAKEN TO LAB. WELL DEPTH : 66 ' . STATIC: 40 ' . WELL SCREEN : 4"X7 ' ST/ST WELL YIELD W/TEST PUMP: 20GPM. 66 DRILLING & CASING 12 .00 792.00 1 WELL SCREEN 4"X36" 300.00 300 . 00 1 WELL SCREENS 4" X 48" 400. 00 400. 00 1 WELL PERMIT 25 .00 25 .00 1 WATER ANALYSIS( standard & VOC'S) 225 .00 225 .00 1 TEST HOLE/LABOR & DEVELOPMENT 200.00 200.00 DEPOSIT REC-D. $1500. 00. THANK YOU! BALANCE DUE: $442.00 2lz 4/15 cn b y C o 0 4— SUB-TOTAL 1 , 942 . 00 SHIPPING CHARGES- 0 . 00 7k T IJ A AI 1! V n l l ,& vJ 9-oo K 0 33 No, Fee------- ------ BOARD OF HEALTH TOWN OF BARNSTABLE YO/7 Application-*rVell Con5truct ion Permit k.00 A�pp ic;gon I Vereby ,ma/de for a pe it to Construct ' �, Alter or Repair ( )an individual Well at: Location Address Assessors Map and Parcel --—-----------———---—----------- Owne Address --- ...... ------ ------- tea Installer i5n-Fle, Address Type of Building Dwelling---—----——---------------------------—-------------- Other - Type of Building------------—----------------- No. of Persons---------------------___--__—____________ Type of Well ----------- Capacity—__/ Purpose of Well--------�AAI—------------ 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 Prytection Regulation — The undersigned further agrees not to place the well in operation u a ate .0 has been issued by the Board of Health. Signed 10 ------------- -- Application Approved By- -7- date- date Application Disapproved for the following reasons: 7^L oai �3 O.V date Permit No. —-----—--------- Issued ........ .............. date - - - - - -- --- ------ ------ ------- -- -----------I- -- --------------------- ----­ - --- - - - ----- - - - ------- BOARD OF HEALTH TOWN OF BARNSTABLE (Certificate Of (Compliance THIS IS,TCE�RTY, That the In dividuol Well Constructed (Altered or Repaired _ by-------- ———------------------------------—--------------------------- Installer at____A_ -—- --- -------------------------------- 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. -1^v-- �000_33Dated___'7 `0_V THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATEInspector—----------------------------------------- —--------- o 33 t ----- No.-------------------- Fee----------- BOARD OF HEALTH TOWN OF BARNSTABLE ,/� 01ppllcation-*rVell Cootruct ion permit App icat"on i hereby made for a permit to Construct ( 4, Alter ( ), or Repair ( )an individual Well at: 1 6� � �G�v� Location — Address Assessors Map and Parcel t nInstaller Owne Driller Ads -- ---------------------- -------- �_tea -ress--s- — Add ,. 4,,Type of Building Dwelling----—------------- ----------------------------------- Other - Type of Building ------ No. of Persons-------------------------_--_—_____________ Type of Well- -� e - - -----_-- Ca acit ��--� '- --—YP P Y--_ - - Purpose of Well------='� - - -- ------- i 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 Pr tection Regulation - The undersigned further agrees not to place the well in operation u a e t .o '1 a has been issued by the Board of Health. Signed - -- --- --- - — --?—��� -- - — date Application Approved By— --- -- -- --- --- -— -� �w�- f date Application Disapproved for the following reasons:---------- ------ -- date �. --------------- Issued----- - Permit No. --------------------------- -- ----------------------------------------------- date 1 ------- ----------------------------------------------------------------------------------------------- BOARD OF HEALTH ,I TOWN OF BARNSTABLE Certificate ®f Compliance THIS IS PERT , That the Individu 1 Well Constructed ( G�Altered ( ), or Repaired ( ) b �`— '( -- ———- Installer at- Gf�_ - _C •- —L`�-- --��-- ,e./3•------------------------------ 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. - _200t��N_ B Dated--._--2-----U THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION`SATISFACTORY. ,.. -------------- - -- Inspector------------------------- DATE-------------�----------------------_- - -------------------------------------------------- y----------------------------------------------------------------------------------- -------------------- BOARD OF HEALTH TOWN OF BARNSTABLE Vell Con5truct ion Permit � 00� — ©3 � No. -----------------— Fee------ Permission is hereby granted: -�� —-—- -- -- --- ---------- — to Const ,uct y 4, Alter ( ), or Repair ( ) an Individual Well at: No. / ----------------------------------------------------------------- street as shown on the application for a Well Construction Permit ` No. -------------------------- -- - ---- -- - - Dated - _=--------------------------------------------------------------------- Q - Board of Health DATE-- - - - Y•r.•. 9.'it••,rT.."n'V.i, h3 !E" :Y .,y S /•,-:;r♦•f:,:,n•' V 3.I �L'^.' t f .""A' - pl'"'o-' A t -`,.-u. 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CADILLAC, PLS P. 0, BOX 258 f � 7 f `= WEST YARMOUTHT MA 0 ` (508) 775--9700 CERTIFICATE OF ANALYSIS Page: 1 b �f Barnstable County Health Laboratory `ads c�tL}sv Report Prepared For: Report Dated: 1.1/14/2008 Jonnilea Marshall Order No.: G0850022 26 Carlson Lane West Barnstable, MA 02668 Laboratory 1D#: 0850022-01 Description: Water-Drinking Water Sample 9: Sampling Location 26 Carlson Lane West Barnstable,MA Collected: 11/13/2008 Collected by: D.Marshall J Received: 11/13/2008 Routine ITEM RESULT UNITS RL MCL Method# Tested Nitrate as Nitrogen 1.4 mg/L 0.10 10 EPA 300.0 11/13/2008 I i.o er 0.36 mg/L 0.i0 1.3 Sivi3iiiB iiii4C:008 pp Iron ND mg/L 0.10 0.3 SM 3111B 11/14/2008 Sodium 13 mg/L 1.0 20 SM3111B 11/14/2008 Total Coliform Absent P/A 0 0 SM9223 11/13/2008 Conductance 240 umohs/cm 2.0 EPA 120.1 11/13/2008 pH 7.0 pH-units 0 SM 4500 H-B 11/13/2008 -- _- -- -� Water sample meets the recommended limits for drinking water of all the shove tested parameters. -- Approved B (La ector) Qr- G. t 3 t 00 fy, -10 Ln t" t� ND=None Detected RL = Reporting Limit MCL=Maximum Contaminant Level Superior Court House, PO. Box 427, Barnstable, MA 02630 Ph: 508-375-6605 � '°f `• CERTIFICATE OF ANALYSIS Page: 1 Barnstable County Health Laboratory �sseKu Report Prepared For: Report Dated: 1/23/2009 Richard Howard High Pointe Inn Order No.: G0950571 70 High Street West Barnstable, MA 02668 Laboratory ID#: 0950571-01 Description: Water-Drinking Water Sample#: Sampling Location 70 High St.West Barnstable,MA Collected: 1/22/2009 Collected by: R.Howard Received: 1/22/2009 Routine ITEM RESULT UNITS RL MCL Method# Tested Nitrate as Nitrogen 7.1 mg/L 0.10 10 EPA 300.0 1/22/2009 - Copper 0.35 mg/L 0.10 1.3 SM 311113 1/22/2009 Iron ND mg/L 0.10 0.3 SM 311113 1/22/2009 Sodium 42 mg/L 1.0 20 SM 311113 1/22/2009 Total Coliform Absent. P/A 0 0 SM9223 1/22/2009 Conductance 480 umohs/cm 2.0 EPA 120.1 1/22/2009 pH 7.0 pH-units 0 SM 4500 H-B 1/22/2009 Sodium level is above the maxium contaminant level. Those on a low sodium diet may wish to consult a physi ' n. Approved By:_ _ (Lab irector) y , e t, +e, ND=None Detected RL = Reporting Limit MCL=Maximum Contaminant Level Superior Court House, PO.Box 427, Barnstable, MA 02630 Ph: 508-375-6605 r 1,33-062 (/_l_ ---- - ------- --- No. ------ Fee--- ---- BOARD OF HEALTH r TOWN OF BARNSTABLE ���Citation,�or�err �ort�truction�ermit Application is hereby made for a permit to Construct (, Alter ( ), or Repair ( )an individual Well at: - 76 -Mel-66A) 1_,4 AJ6- ---------------------- ---`r /274P_ea 3_ -'11'06 6-Z — Location — Address Assessors Ma and Parcel . P f2icerrv�— `SS e�,DA& 14AIA RAOi�'Le-=/a Ns Owner Address mcan�__wcL( LL�ivG ��� -� -'�� a7s''3- - ®�ZFa�vs /1,1,4 Gs'3 Installer — Driller Address Type of Building t/ Dwelling------------ Other - Type of Building--------------- No. of Type of Well _-�- --- Capacity- - - - Purpose of Well--3OMe417 e - --------- 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. Signe — ------------ -- -—--— — --- —e datA lication A roved B 1*0 _________ dA PP PP Y— — ate Application Disapproved for the following rea ns: r date Permit No.----------- ----- Issued------------� -��---- ------ ------------- date BOARD OF HEALTH TOWN OF BARNSTABLE Certificate ®f Compliance THIS IS,Lp CERTIFY,`Tha.,t the I dividual Well Cojastruc ,,dr( ), Altered ( ), or Repaired ( ) by------�IJ�SI �V�1__� � 1�(_ --- --- - - -- --------- -- at------4&__� o — Il has been installed in accordance with the provision, f the Town of Barnstable Board of Health Private Well Protection Regulation as described in the application for Well Construction Permit No.v//� _-Dated------------------- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE - — - —- - - —-------------------—- --- — Inspector-—- - ------------------------- — - - - i / -----`- Fee--z---------------- ` BOARD OF HEALTH TOWN OF BARNSTABLE Appricationr•�'orlVell �tConotructionV -mit Application is hereby made for a permit to Construct (✓), Alter ( ), or Repair ( )an individualWell at: Location — Address Assessors Map and Parcel - � t .5S f �lD _ c' r' StT'uCTJo c/Clot i t' — — —--------------------------------- - ----------------- -------------------------------------------- Owner Address Installer — Driller Address Type of Building LI-. Dwelling-------------------------------------------------------------- Other - Type of Building ------ No. of Persons-------------------------------------------------------- Type of Well— -- --- —- - — --- - Capacity ------------------------------------------------ Purpose of Well .to'-f)M77e--- ----------------- 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. Signe /_ -�: ---- -- - 7- - ---------- - - -- ° datf ---------- Application Approved By—, ----(/-, ?- ------- -��`(✓ ________ _ PP PP ---G- - /date Application Disapproved for the following re ns:------------------------------------------------------------------_--------------_-_-----_____________ date Permit No. --- Ad- — -- —--- Issued -- - `- ------- ------------------ date I BOARD OF HEALTH t - TOWN OF BARNSTABLE Certificate Of Compliance THIS IS TO CERTIFY, T at the Individual Well Construc ed ( )y Altered ( ), or Repaired ( ) Installer �'A)2�p� Vie. r -I - ,� _ �;',. at-__ — — — — — v T ; --- -- 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.(�t-�r 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 Very Con5truct ion Permit No. Fee-----"------------- Permission is hereby granted. 1 —mil ------------------------ to Construct (X), Alter ( ), or Repair (, ) an IndividualWell at. ' No. �C �'� l 1�flr �a��� ✓ l_I !� 1------- -• L Cst eet / V f as shown on-the application for a Well Constructon_Permit JC/A / 7� No.- --- -------- -------- - Dated --- --- - - -i- - - - Board fo Health DATE---- ---�-— --------------------------------------------- L/ J-' � �� . LEGEND x 53.4 52.9 S' WELL / y? PROPOSED CONTOUR S� \ s 51.2 / 72 - EXISTING CONTOUR g6 23 c k P UNDERGROUND . PHONE WIRES N \ \ j o E UNDERGROUND ELECTRIC WIRES / \ _>0 - x 51 . LOCATION FROM C UNDERGROUND CATV WIRES % x . 4 ASBUILT CARD 0 49.5 -- - I' / \ x _ _ x 8.50 x 69.3 ..EXISTING GRADE, PROPOSED GRADE ('x' MARKS SPOT) � 50 . 47.7 � I 150' BOULDER 46.2 LOT6 x 42.9 G 45.7 x 45.5 E dui 2.3 \ �+ UTILITY POLE / x 7.5\ �N x 0.5 TH1 TEST HOLE AND NUMBER SEE SHEET 2 I 4 .0 -_------___ �S PROPOSED ( � � ._ \ WELL LEACH PIT --_ PROPOSED RIP-RAP WALL _� _ 70 ' \ \ 42.1_ x 2 - S _- \ x 9 N PROPOSED LANDSCAPE TIE WALL 150' I J = STANDING WATER -- N 12 29 94 39.9 _ \ x 2.50 41. 4 I I 0.3 J / WELL I 4 ✓' X / Cam-52 5 X 45 0 �FSz 5 40. 39.3- _ 00 40_ -� i \ _X_- 40. 44.2 51. � NOTES •�4 , I X 47.0� 43.8�' / x 46.8 X 6 / pj l 40 \ �. x 4 !G / / 44.9< 0.3 38.4tK- co so, \ 1 . LOCUS IS ASSESSORS MAP 133 PARCEL 62. I x 2 44.4 2. ELEVATIONS ARE NATIONAL GEODETIC VERTICAL - x 6 J 40 I L\O \� - / x 36.4 x 7.2 DATUM 1929. � 6�° �' - o /, � x 49.9 � / / / � �2 36.9 3. LOCUS IS IN FLOOD ZONE C ON FIRM FLOOD co X 4.7 /- STAKED HAYS WORK LfMIT�NE / / J pip INSURANCE 'RATE MAP DATED JULY 2, 1992. J ca / o ` \ ��• / x 36.9 4. STAKED HAYBALE WORK LIMIT TO BE SET IN x 73.d o � X 58.4 � \ •4 / PROPO D WELL WATER48 6 / � � / x 36.4 \ PLAC PRIOR TO ANY CONSTRUCTION AND !, N / / SU�LLINE 386 LEFT IN PLACE TILL LANDSCAPING IS WELL ^ / 0 x 5 1 / x 49.9 3 / / `� / ESTABLISHED. 37.7 / 62 2 / x 6.4 5. THE LOCUS APPEARS TO BE IN AND RF ZONING x 75.9 oo4 x qg / �TRICT. APPARENT YARDS ARE. I 49.9 D / x 4 / 2 FRONT YARD 30' 73.2 / / x 4 4 40.5 SIDE YARD 15' 6 0 -___ ''" / REAR YARD 15' x 69 __ _ / / WELL ACTUAL ZONING DETERMINATIONS MUST 'BE ¢ r - ... + 2 MADE BY TOWN ZONING OFFICAL. 54, 2.2 755 6 x = ti _�= .4 --- -_ Z. i 70.0 - p - - _ o� � - 43 3 72 x 8 x 49.9 10 49 5 70.9 71. � x x F�5.7 70. 3_ 70.4 ' 6 �n� =- op 45.1 2 x 74.0 P I -`�S p0 s. - D Ox s x 47.2 THIS PLAN IS A VALID COPY ONLY IF IT BEARS AN -_ x t __ f. /- \Oo. ORIGINAL STAMP AND SIGNATURE. 7 0 .0 7 2+ / - p49.4 x 47.6 y�Gf tlS,� ��NO qss 64 N I / _ __ 7.4 Rfl^BALD ti � RONALD �yG _-_ LOCATION FROM �� CADILLAC - 4 CADI..LAC #1060 a _ y x 3 _�� 6 0.1 ASBUILT CARD #35779v Al 67.8 x 67.5 69 67.9 __p, `h�`- H x 8 1.4 LEACH PIT _ q�i -T s 6 4� s �1TAR 1 x 6 \ � --- x 55, x 6 7Cj 66.4 52 65. O(o�' Oj� 52.5 \ REVISION NOTES: \ 30' x 53 3.0 x 52.5 65�\ � 6.2 �� x 6� SHEETS�� � 53.1 1/25/95 - HOUSE FOOTPRINT SHRINKS �I TOP SOUTH CORNER OF CONC. 65.7 7 \ 64.7 1.9 2/17/95 - WATER SUPPLY LwEE& WORK LIMIT BOUND = 67.65 NGVD 1929 �5 4.6 x 5 SHEET ONLY REVISED SITE PLAN 0 9.7 I x 62.7 7 STONE x 61 .4 8.0 r 2.0 55.6 c OR 5 " x 63. 3 6° 0 x 55.7 DETAIL _.. _ _ 20 R . MAYNARD & DONNILEA MARSHALL 0.4 _ 0.2 I 5.5 9.8' \ lX 57.9 ' AT / J \ INSTALL 2-6' X 4' DEEP LEACH PITS 9.8 FEET ON CENTER WITH 2' OF STONE ALL AROUND. SEE ABOVE DETAIL LOT 7 v 26 CARLSON LANE , WEST BARNSTABLE , MA �> » 62. X 61.7 INSTALL AN H-10-1500 GALLON SEPTIC TANK 1995 SCALE : 1 = 20 TOP OF PK NAIL IN PAVEMENT x JA N UARY 1 � � I ELEV.= 62.54 NGVD 1929 59.2 8.6 REVISED JANUARY 25, 1995 x 61.3 PROPOSED RETAINNING WALL PER NORTHSIDE DESIGN SITE GRADING PLAN DATED JAN. .6, 1995. 62. ' .. REVISED FEBRUARY 179 1995 _ I RoNALD J. CADILLAC PLS IRS x625' PROFESSIONAL LAND SURVEYOR & REGISTERED SANITARIAN P. O. BOX 258 WELL 2.2 WEST YARMOUTH, MA 02673 10 HEALTH AGENT APPROVAL DATE (508) 775- 9700 SHEET 1 OF 2 I - -- - - - - - _---- _ _ _.._ ._ _____ _-_ ._ .. -- _ _. - -- - 1 4 i I SYSTEM PROFILE HORIZONTAL SCALE: 1 4'f VERTICAL SCALE: 1 " 4' - NOTE:_ INVERT_ ELEVATIONS,_ EXISTING & PROPOSED - - - - - - - - - - - - - - - - - - PROPOSED GRADE - - - - - - - - - - - - - - - - - - - - _ GRADES, AND FOUNDATION SCALE 'CORRECTLY. o FACE OF RIP-RAP * ON SEPTIC COMPONENTS WRITTEN DIMENSIONS HOLD. ELEV. Q WALL - - - - - - - - - - - - - - - - 68 foundation 0 oundat o z i _ design by .others - o - - - - - - - _ , _ _ - - - - - - - - CONSTRUCTION NOTES 64 z - - - - - - - - - - - - _ - - - - - - - - - - - - - - -- - - - - - - - - - - - - - top basement 0 BUILD UP CHIMNEY WITH U IF UNSUITABLE SOILS, slab = 62.3 -� MORTOR TO WITHIN 1' OF GRADE. OR SOILS 62 - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - DIFFERING FROM THE SOIL LOG ARE FOUND, CONTACT THE 60 - - - - - - _ - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 60 BOARD OF HEALTH AND 4 sch 40 pvc 4' MAX. R. J. CADILLAC. COVER 58 - - _ _ - - - - - - - - - - - - - - - - - -2" MIN. 6 S=.02 56 0,> - -- - 14" - - - - _ _ _ - - - - - - - - - - - - - - - - - - - - - - ALL CONSTRUCTION TO MEET 54 INVERT 57.18 - - - 4 - 0 - 5' 8" - . . .4" -sch 40 pyc - - - - - - - - - - - - - - - - - - STATE SANITARY CODE AND EXISTING GROUND TOWN OF: BARNSTABLE BOARD INVERT 56.80 r iT� - - - - - - - - - - 52 - - - - - - OF HEALTH REGULATIONS. 10' 6 50 - - - - - - - - - - INVERT 56:55 - - - - - - - - - - - - - - - - - - - - - - - - 50 S� SO 48 _ - - - - - - - - - - - - - - - _ - - - - - - - - - - - - - H--20 D-BOX - - - - - - �_ BUILD UP CHIMNEY WITH PROVIDE SANITARY TEE MORTOR TO WITHIN 1' OF GRADE. 46 - - - - - - - - - - - - _ - - - -- - - - - - - - - - - - - - - - -& WATER- TE-ST -D--BOX - - - - - - - - - - H- 10 1500 GALLON SEPTIC TANK - - - - - - - - - - - I - - - - - - -_ 2" MIN DEPTH OF 3/8" 44 I CLEAN WASHED PEASTONE 2„ .. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 2' M WASHED 42 -INVI=RT 43.95 _ _ - - .,, �.: IN OF CLEAN INVERT 43.78 3/4„ TO 1 1/2" STONE SEE SITE PLAN FOR LEACH AREA SHAPE INVERT 43.70 r 25° 2'level .38 10 * BOTTOM 39.7 36 THIS PLAN 1S A VALID COPY ONLY IF IT BEARS AN 4.0' ORIGINAL STAMP AND SIGNATURE. - - - - - - - - - - - - - - - - - - - - - - - - - - 3434 i BOTTOM TEST HOLE r. _ . (� q q��� r MASS 2 H-20 LEACH PI TS �'FQ RON L s9°ti �� RONALO o M G JANES N JAES "�'' CADILLAC CADILLAC o �; v #35779 v v 9�#1060�a SOI L LOG SURV �4 �AtITAN-N TEST DATE: DEC. 20, 1994 �, IS PERFORMED BY: RON CADILLAC WITNESSED BY: EDWARD BARRY PERC RATE: < 2 MIN./IN Soils qualified by perc are shaded TEST HOLE 1 TEST HOLE 2 WATER TABLE: NOT ENCOUNTERED DETAIL PLAN DEPTH EL. DEPTH EL. FOR 0 54.0 0 51 .7 TOPSOIL TOPSOIL< SUBSOIL ' SUBSOIL R . M AYN ARD & DONNILEA MARSHALL 2.0 52.0 2.0 49.7 DESIGN DATA TIGHT TIGHT AT SILTY SAND SILTY SAND NUMBER OF BEDROOMS: 3 _ GARBAGE GRINDER: N06.5 - - _ _ 47.5 8.0 43.7 LOT 71 26 CARLSON LANE , WEST pp AR N S TAR LE , MA - REQUIRED CAPACITY: 330 GPD (110/BR) Y 11 , 1SCALE : AS SHOWN ._ ___ � � 5 PERC __ MEDIUM . SAND MEDIUM SAND SEPTIC TANK SIZE: 1500 GALLON JAN U AR=- _ ._ BOTTOM LEACHING AREA: 176.5 SF 8.0 = SOME SILT = SOME SILT -- CIRCLE-3.14 X (5'x5')= 78.5 SF REVISED JANUARY 25, 1995 = RECT,-9.8' X 10'= 98 SF 1.2.0 42.0 11 0 _ 40.7 SIDE LEACHING AREA: 204 SF REVISED FEBRUAR I�/ 17, 1995 MEDIUM SAND = MEDIUM SAND (3.14 X 10 + 2 X 9.8 4 DESIGN CAPACITY: 686 GPD RONALD J. CADILLAC, PLS, RS _ - 176.5 GPD �____ ______ BOTTOM-176.5 SF(1 GPD/SF) - 16.0 = ____ ____ -  __ 38.0 16.0 _ ___ 35.7 PROFESSIONAL LAND SURVEYOR & REGISTERED SANITARIAN SIDE-204 SF 2.5 GPD SF - 510 GPD ( / ) - P. O. BOX 258 WEST ` YARMOUTH, MA 02673 HEALTH AGENT APPROVAL DATE - _ (508) 775- 9700 _ SHEET 2 OF 2 4_ LEGEND WELL PROPOSED CONTOUR EXJSTIN&'CONTOU-R - UNDERGROUND. PHONE WIRES AIQ ->o E UNDERGROUND ELECTRIC� WIRES LOCATION FROM C, UNDERGROUND -CATV WIRES ASBUILT CARD 69.3 RADE (V: MARKS SPOT) EXISTING GRADE, PROPOSED G 150' BOULDER 4 LOT 6 UTILITY POLE' 4'1 PR/O ED LEACH PIT TH1 TEST HOLE AND NUMBER (SEE SHEET .2) K L PROPOSED RIP-RAP WALL 70' d TED, w s 150' STANDING WATER PROPOSED LANDSCAPE TIE WALL " ON 12/29/94 WELL 00 4 0� NOTES co LOCUS IS ASSESSORS' MAP , 133, PARCEL 62. tk j 2. ELEVATIONS ARE NATIONIAL GEODETIC VERTICAL 0 10 L\O T \7 STAKED HA7,Att WORK LIMIT�IN L -70NE C ON FIRM FLOOD 3. LOCUS IS I N FLOOD DATUM 1929. INSURANCE RATE MAP DATED J U L Y ez_l, 1992. PROPOSED WELL WATER'�.� . ........... 3 r4 4. , STAKED ,HAYBALE WORK -LIMIT TO BE SET IN SU P-PLY LINE PLACE PRIOR TO ANY CONSTRUCTION, AND LEFT IN- PLACE TILL- LANDSICAPI NG- IS WELL 4 ESTABLISHED. 57 5.' THE LOCUS, APPEARS TO BE IN, AND RF ZONING DISTRICT. �APPARENT YARDS ARE. 4- FRONT .YARD 301 2 T SIDE YARD 15' WELL Q) REAR YARD' 15' ACTUAL ZONNG'�DETERMINATIONS M U.ST B F MADE BY TOWN ZONING OFFICAL. 7. 7 10, "o, J THIS PLAN IS A VALID COPY ONLY IF IT BEARS AN D ;�BOX TURE. ORIGINAL STAMP AND SIGNA I \vle A\ + ol jH 2 tK' RON) LOCATION FROM JAMES JAIVIES 's CADILLAC CADILLAC ASBUILT CARD 0 106 LEACH PIT #1060 0, H Il �b S"T ITA C) lb 4, TOP SOUTH CORNER OF ' CONC'. 9 BOUND 67,65' NGVD 192 0 STONE Q) - 5 Sl TE PLAN �P Y�-1 7, DETAIL FOR , 1 220, 4 9.8' -vu 0 " & DONNILEA MARSHALL R . mAYNAr INSTALL 2-6' X A' DEEP LEACH PITS 9.8 FEET ON CENTER W ITH 2' OF STONE ALL AROUND. (SEE ABOVE DETAIL) AT -10 1500 CALLON SEPTIC TANK INSTALL AN H MA LOT 7 , 26 CARLSON , LANE , WEST BARNSTABLE TOP 0 F P K NAIL IN PAVEMENT E.LEV. 62-54' NGVD 1929 JANUARY 11 1995 SCALE : 1 . 2071 'PROPOSED RETAINNING WALLS PER NORTHSIDE DESIGN SI TE GRADING PLAN DATED JAN. 6r, 1995. RON ALD J. CADILLAC, PLS, RS PROFESSIONAL LAND SURVEYOR & REGISTERED SANITARIAN P. O. BOX 258 -'A WEST YARMOUTH, MA �02673 775- 9700 'WELL 150' HEALTH AGENT APPROVAL DATE SHEET 1 OF 2 _ SYSTEM PROFILE HORIZONTAL SCALE. 1 4 f w ` . - VERTICAL • �.. A LE. 4 . SC_ NOTE: INVERT "ELEVATIONS, NS EX TNG .& PROPOSED GRADES ANDFOUNDATIONSCALECORRECTLY. - - _ *_ 0NDIMENSIONSSEPTIC COMPONENTSE NTS WRITTEN HO LD, ELEV . Q I o I foundation z _. design b Y n others � 0 CONSTRUCTION N TI N T S UC 0 NOTES G .. 64 ' ctoP basement S D GRADEROPO s0 6 .3 b 2 62 IF UNSUITABLE SOILS 0R SOILS E OF RIP-RAP DIFFERING 0 f AC FROM THE SOIL LOG - WAL L �x 60 H ARE CONTACT T 60 E FOUNDE 4 v _ , 4 s h 0 c P MN Y WITH 1 P M BUILD U CH E 4 AX. T , H I R F ,H A AND MO RTOR TO WITHIN 1 OF GRADE. BOARD 0 HEALTH COVER _ 5 RCADILLAC.., A I^ o . J. C D S 2 0 2 MIN : , .: 6 6 5 LT10" :14: T MEET o. E E A CONSTRUCTION , LL 5 4 _ 4 0 5 8 „_ T AND T SANITARY DE D R TA CO` IN T 56. STATE S INVERT ND _EXISTING G OU M F RN TABOARD_T WN A E _ 0 B BL 52 c 0 S I INVERT RT 6.00 : VE , F AREGULATIONS.H TH ` 0 E L _ _ _ 50 101 6 4 h' 40 vc 50 sc P INVERT ' 5.75 E 5 X- io p BO ' 0 8 _ < I i HIMN Y WITH BUILD U C E WITHIN 1 OF GRADE.M T R TO THI SANITARY TEE OR 0 PR PROVIDE�, 0 DES SEPTIC TANK 1 1 GALLON P N - ��H E C G L S 0 500 1. 0 WATER TEST X S D 0 �-5 & E E B i I - IN PTH ' F /� -- M 0 3 8 2 DC A H P A N, . 4 I � LASED ST _4 CLEAN E 0 2 - E : 7 A�J 0 CLEAN WASHED R 2 MIN. 4 INVERT � 95 Ira R 4 .7 V 8 .�E ,� t I - 4 T� 1 ,1 2 STONE PJ 3 0 E _ - PLAN R _LEACH AREA SHAPE)P A 1- C T L 0 LE E S E: SEE SITE s I N 4 INVERT RT 3 0 E , P i i 2 � e ti y 7 10 f BOTTOM39 t 36` { .fl: , F i SF AN ,T AP COPY, Y I BEARS l N I E PLAN VALID ONLY -il� � L I L 34 .. r r P I ATURE. TA �( AN S .� ORIGINAL S D T '. ��A TEST HOLE E ;� 0 S L B E -- H PIT H A 20 LE S - 2 C r s M s 9 , P , 9 O 0 BONA D SOIL 0G RONALD ti � G S L G O N o AMES J JAMES � m -, m -, CAD LLAC t ti CADILLAC 0 1060� v 3 79 0 v # 57 9 P P S S T 6 FESS\ 1 4 q P 9 TEST AT DEC 20 9 � ES DATE: N , f A N T A O SU Y- RON CADILLAC P RF PERFORMED E 0 ED B WAR ARRY ITN Y. ED D B WITNESSED B E - �` MIN. IN . P R RATE < 2 PE RC i r rshaded� � c e Soils -qu alified f e d k� e a P q YE I T ENC OUNTERED NCOJ ERED WATER TABLE: 0 E TEST H E BL HOLE 2 T H 1 ES 1. T HO LE LE P T EL, DE PTH P TH EL. DEPTH PLAN DETAIL N 4 0 51 .7 I DE L L 0 5 .o TOPSOIL . TOPSOIL FOR I SUBSOIL 0 SUBSOIL 49.7 N DA TA . 2,0 20 g DES G D _ 20 5 - - TIGHT TIGHT TG T I AMARSHALL MAYNARDNN 0 � E8c D4 R MACTUAL)R S N M ER OF BED 00 TY AN U B I TY AN SL S D SILTY SAND GRINDER: NO R DE ._ GARBAGE G 4 7AT G B E 4 7,5 8 (� 3. 4 � P 110 R 0 D_ I G B I CAPACITY: R R D C C.. E U E �., - GALLON P TANK 1500 C LLO SEPTIC A SI ZE: M A _ SE C ME SAND T A A M T BARN STABLE , M AND _ A W � S _ . MEDIUM S AR N LANE , ES P RC _ _ T 7 � C ESO _ _ . E LOT 2 a 1 F AREA: 76:5 LEACHING R S E C E M IT BOTTOML M lT 0 E SILT _. E S 8.0: SO L . I_ N A H W _ A 0 _ 1 SC L E AS - SHOWN Y 1 �AR 95 7 . F - g� X 8 ..,j s A N .CIRCLE 3. 4 X 5 5 J U _ F . 1 9 8 S R C 98 X 0 E T 40.7 _ ' 1 . 0 42. 10 1 0 _ 2.0 _ .� CADILLAC, L S R 4SF R NA D J. C AD S _ A HiNG AREA. 20 0 L S DE LE C _ F 4 20 , S+ x SANITARIAN 4 s VITA N _. 31 x 10 2 8 REGISTERED R SA _ SURVEYOR & REG S E ED PROFESSIONAL'TONAL LAND SU E ) O o Ess MEDIUM SAND E D UM N _ MEDIUM A D . .S 6 P 6 8 G D NCAPACITY: D ES G X 8 P 25_. BO_ : : . 0 1 6 PD _. F 1 P SF 5 G 7 G D TT P�1 1 6 5 S B 0 0 A 73. T 6 _ . . , . .. .. . . _ H M 02. _. . . . 'WEST YA M U _ . . ) S R 0 , 38.0 6. 0 35. 1 6.0 _ 1 P _ F F G D P 0 4 S S 5 G D S DE 20 2_ 775 9700 ( 5 Q8 . _ H A APPROVAL AT HEALTH AGENT V L DATE EAL GE 0 2OF` 2 -SHEET >