HomeMy WebLinkAbout0207 CARLSON LANE - Health 207 CARLSON LANE
WEST BARNSTABLE
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C R T I F I 'AT ". ANAL i SgS Pag,: 1
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Barnstable Count Health Laboratory
7 ;� Report Prevared For: e' y '
,^ 1. P — Report Dated: 12/29/2008
Ed Bower Order No.- G0850346
' 207 Carlson Lane '?
$ West Barnstable, MA 02668
_ .
JU!at(ti r #: 0850346-01 Description: Water-Drinking Water i
Sa MP1e n Sampling Location 207 Carlson Ln,W.Barnstable,IV1A Collected 12/18/20QR
�. t:r,llected by: D.Bower ) Received: 12/18,12009
t I_fT.td>( RESULT UNITS RL iMCL Method# Tested
1 �,
f 1litrate a iv xtrogen 1.6 mg/L 0.10 10 EPA 300.0 12/18/2008
F _ 0.18 mg/L 0.10 13 SM 311113 12l23/2008 .
:.V... . ND mg/L O.i0 0.3 SM 3111B 12/23/2008
�]Od:131]lt. 15 mg/L 1,0 20 SM 311113 12/23/2008
regal Codicrm
Absent Ri A 0 f.1 SM9223 12/18/2008
;Cnlduclam 140 umchs/cm 2.0 EPA 120.1 12/18/2008
I a! 6.6 pl-l-units 0 SM 4500 H-B 12/18/2008 i
WO'e?sN 191ple meets the recommended limits for drinking wrat.s:r of all the above tested.parameters. i
Approved B =-'i;.:...-
(La hector)
A�'
t
2 '�
i
` 'H ND=None Detected RL = Reporting Limit MCL=Maximum Contaminant Level .
Superior Court Douse, PC.Box�z27, .Barnstable, MA 02630 Ph: 508-375-6605 !
is �'.
E
al:,
r
f`�F hAti CERTIFICATE OF ANALYSIS
4
4 M�; Page: 1
Barnstable County Health Laboratory
\ssnClilS'�'lY Report Prepared For: Report Dated: 12/29/2008
Ed Bower Order No.: G0850346
207 Carlson Lane
West Barnstable, MA 02668
Laboratory ID#: 0850346-01 Description: Water-Drinking Water
Sample#: Sampling Location 207 Carlson Ln.W`Barnstable n'IA
Collected: 12/18/2008
Collected by: D.Bower Received: 12/18/2008
Routine
ITEM RESULT UNITS RL MCL Method# Tested
Nitrate as Nitrogen 1.6 mg/L 0.10 10 EPA 300.0 12/18/2008 ----
Copper 0.18 mg/L 0.10 1.3 SM 3111 B 12/23/2008
j Iron ND nig/L O.i O 0.3 SM 3111 B 12/23/2008
SOdiurn 15 mg/L 1.0 20 SM 3111B 12/23/2008
Total Coliform Absent P/A 0 0 SM9223 12/18/2008
Conductance 140 umohs/cm 2.0 EPA 120.1 12/18/2008
pH 6.6 pH-units 0 SM 4500 H-B 12/18/2008
Water sample meets the recommended limits for drinking water of all the above tested parameters.
Approved B
(La irector)
ND=None Detected RL = Reporting Limit MCL=Maximum Contaminant Level
Superior Court House,,PO. Box 427, Barnstable, MA 02630 Ph: 508-375-6605
CERTIFICATE OF ANALYSIARNSTABLE
Page:
Barnstable County Health Laboratory0 [?
HrSACHU�i
Report Dated: 4/4/2005 ')9d5 APR -I AM I I. 5 Z
Report Prepared For:
Order No.: G0529596
Ed Bower .— �C ISION
207 Carlson Lane
W Barnstable, MA 02668
Laboratory I.v#: 0529596-01 Description: Water-Drinking Water
Sample#: 29596 Sampling Location 207 Carlson Ln.W.Barnstable,MA Collected: 3/31/2005
Collected by: E.Bower Received: 3/31/2005
Routine
ITEM RESULT UNITS RL MCL Method# Tested
LAB: Inorganics
Nitrate as Nitrogen 0.66 mg/L 0.1 10 EPA 300.0 3/31/2005
LAB: Metals
Copper 1.4 mg/L 0.1 1.3 SM 311113 3/31/2005
Iron BRL mg/L 0.1 0.3 SM3111B. 3/31/2005
Sodium 25 mg/L 1.0 20 SM 3111B 3/31/2005
LAB: Microbiology
Total Coliform Absent P/A 0 Absent 309 3/31/2005
LAB: Physical Chemistry
Conductance 130 umohs/cm 1 EPA 120.1 3/31/2005
Sample has higher than average levels of Sodium.Those on a low Sodium diet may want to consult a physician.
Approved
(La irector)
i
RL = Reporting Limit
MCL=Maximum Contaminant Level
Superior Court House, PO. Box 427, Barnstable, MA 02630 Ph: 508-375-6605
. Page: 1
yor
CERTIFICATE OF ANALYSIS
Barnstable County Health Laboratory
Report. Dated: 3/24/2005
Report Prepared For:
Order No.: G0529505
Ed Bower
1
207 Carlson Lane
W Barnstable, MA 02668
Laboratory ID#: 0529505-01 Description: Water-Drinking Water
Sample#: 29505 Sampling Location: 207 Carlson Lane,W.Barnstable,MA Collected: 3/22/2005
Collected by: E.Bower Received: 3/22/2005
Test Parameters
ITEM RESULT UNITS RL MCL Method# Tested i
LAB: Metals
Hardness BRL mg/L as CaCO 0.1 SM 2340B 3/24/2005
LAB: Physical Chemistry
PH 6.5 pH-units 0 EPA 150.1 3/22/2005
Water sample meets the recommended limits for drinking water for all above tested parameters.
Approved By:
ab Director)
RL = Reporting Limit
MCL=Maximum Contaminant Level
Superior Court House, PO. Box 427, Barnstable, MA 02630 Ph: 508-375-6605
I
`Y a
No. ------------
BOARD OF HEALTH
TOWN OF BARNSTABLE
01pp[ication-*rVell Congtruct ion Permit
0 -7, 1��14ZsAA —r
Application is hereby made f r a permit o Construct ( ), Alter ( ), or Repair ( )an individual Well at:
Location — Address Asses s Map and Parcel
off- y s d r✓
r Owner Address
----------------—-------------- ------------------— —— — — —---------------
Installer — Driller Address
Type of Building
Dwelling---------------------------------------------------------------
Other - Type of Building -------- No. of Persons--------------------------------------------
Type of Well- - - ----- ------- Capacity-------------------- - - - - - —- -
Purpose of Well-------- - --- --------
Agreement:
The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The
Town of Barnstable Board of Health Private Well Protection Regulation - The undersigned further agrees not to
place the well in operation until Certificate .of Compliance has been issued by the Board of Health.
Signe -----_----_--_ /�_
da
Application Approved By ..-ice»-�-- -- -=1sz-=-�—__
------—— date
Application Disapproved for the following reasons:------------------------------------------------------------------------------
----------------- -- -
�, date
Permit No. --- `—=J --=- ---------- Issued--------
--------------------------------------------------
date
BOARD OF HEALTH
TOWN OF BARNSTABLE
Certificate ®f Compliance
THIS JS T ) CE TIFY, at the Individual Well Constructed ('), Altered ( ), or Repaired ( )
by-04- "=`� - ---------------------------------------------------------
Install r
a t------— —-� _ � �/- ----&)- ---4-,-- --- - - ---- ---
has been installed in accordance with the provisions of the Town of Barnstable Board ofHealth Private Wel Prot ction
Regulation as described in the application for Well Construction Permit No. --L-Y-=- Dated�-'2-0��-
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL
SYSTEM WILL FUNCTIIION SATISFACTORY.
DATE Inspector--------------------------------------
�./ ��------------
No.��--�-�t-_-:_�_� - Fee- ---- -
"'` BOARD OF HEALTH
TOWN OF BARNSTABLE
Application for Vell ContructionPermit f
Application is hereby made f r a permit o Construct ( ), Alter ( ), or Repair ( )an individual Well at:
Loa' n — Address I Asses' Map and Parcel
"r ------�a-U/� - ---- ------- - Qom- � - - -
--
Owneerg Address
+ — y--`-------———---—-—-—------------ --------------------------------------------------—--—--—-—-----------—---—-—---------------
lm5i�,, — Driller Address
Type of Building
Dwelling------------------------------------------------------------
Other - Type of Building —------------------- No. of Persons--------------------------------------------
Type
ofWell- -- - -- - - - --- _--
-- -- ------ -------------------- Capacity---------------------
Purpose of Well---------- ------------------
Agreement:
The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The
Town of Barnstable Board of Health Private Well Protection Regulation - The undersigned further agrees not to
place the well in operation until Certificate .of Compliance has been issued by the Board of Heath.
Signe -- date ----—
Application Approved By— {k ---- = -_- ---
V V— —— —— —— date
Application Disapproved for the following reasons -------------------------------------------------------------------------
----------------------- -- -----
---- - ---------
date
Permit No. // Issued--- -- - - --- ---— ---
date
BOARD OF HEALTH
TOWN OF BARNSTABLE
Certificate ®f Compliance
THIS S TP CE TIFY, Pat the Individual Well Constructed ("), Altered ( ), or Repaired ( )
by- -_ - - = ---- -=- ------- ---------------:----- ------- - ---— - - ----- --_ Install —
AV
at----------J-��-- - _ ta ,------ -------- -- - - - _
has been installed in accordance with the provisions of the Town of Barnstable Board ofHealth Private We,)Prot ction
Regulation as described in the application for Well Construction Permit No. --1- -=- Dated ----- -----
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL
SYSTEM WILL F NCTIIION SATISFACTORY.
Z - --- -- Inspector---------------- - --- ---
----------
DATE- -- - — — --------
e..,s�..
BOARD OF HEALTH
TOWN OF BARNSTABLE
U)eCY Congtruct ion Permit
No.'�1-- -ua-=-`-�}-6-- Fee--; ------
Permission is hereby granted =V - 'P� —-- ------ - ---------- - -- -
to Construct (V Alter ( ), or�Re air ( ) an Indi idual Well at:
No. - --- ---- — — ----- -- --— ---- -- - -
st
as shown on the application for a/Well Construction Permit
No. -------------- Dated------ -' =- �� --------------------------
-----------
----------- -- --------------------------------------
B and of Health
DATE_ �r� �---- -- ----- -
` W W- S G
Department of Environmental Management/Division of Water Resources
WATER WELL COMPLETION REPORT
WELL LOCATION �l
Address n rA A?L Sra a/ 6./ n
City/Town �R !�'�'f_Ata,?lb- �Ar 1fi—
G.S.Quadrangle Map y r
Grid Location Owner rR R x a, r 2
Address �/�✓��
WELL USE CONSOLIDATED WELL
Domestic Q�Public ❑ Industrial ❑
Type of Water-bearing Rock
Other
Water-bearing Zones
1) From To
Method Drilled l /1/Q S�
/ - 2) From To
Date Drilled 3) From Tc
4) From To
CASING Depth.to Bedrock
Length Diameter
Type PI/ (., ` UNCONSOLIDATED WELL
STATIC WATER LEVEL Water-bearing Materials
Feet below land surfa�ce rC,)" Sand: fine❑ medium❑ coarse❑ s
Date measured C//F1// 1/ Gravel: fine❑ medium❑ coarse®"
r Screen:
GRAVEL PACK WELL Slot* /` length r from") to/Vj
Yes ❑ No
Split Screen (or 2nd screen)
WATER QUALITY TESTS MADE SlotO length from to
Chemical Q� Biological ❑ Depth To Bedrock
PUMP TEST
Drawdownl Q feet after pumping days hours at / A GPM.
How measured,40 Recovery 1 feet after hours.
LOG of FORMATIONS COMMENTS: (On well or water)
Materials From To
0
/Iti17
S /1i17 1lJ Sd) m
// DRILLER m
Firm J -!!/ j (/Y1
2 Q � Address ��n 5/A X In \
<r9h.l� City
xU oa Registration/No. r l�
( / Operator's s nature
Please print irm y BOARD OF HEALTH COPY 25M 10-85-807101
f
ENVIROTECH LABORATORIES, INC.
MA Cert. No.: M-MA 063
449 Rte. 130 . Sandwich,MA 02563
(508)888-6460 . 1-800-339-6460
FAX(508)888-6446
CLIENT: Ed Bower LOCATION: Lot 4
ADDRESS: 201 Carlson Lane Carlson Lane
W. Barnstable, MA W. Barnstable, MA
02668
SAMPLE DATE: 9-22-94
COLLECTED BY: L.Wile & Son DATE RECEIVED: 9-22-94
TIME: 8:OOAM SAMPLE ID: 4CL
JOB TYPE: New Well WELL DEPTH: 140' 4" PVC
FLOW: 10 G.P.M.
RESULTS OF ANALYSIS:
Parameters Units Recommended Result
Limit
Coliform bacteria/100ml (MF Method) 0 0
pH pH units 6.0-8.5 6.93
Conductance umhos/cm 500 94
Sodium mg/L 28.0 8.92
Nitrate-N mg/L 10.0 0.26
Iron mg/L 0.3 0.06
Manganese mg/L 0.05 0.004
Hardness mg/L as CaCO3 500 20.8
Sulfate mg/L 250 2.5
Potassium mg/L 20.0 0.72
Alkalinity mg/L 200 15.2
Chloride mg/L 250 18.7
Turbidity NTU 5.0 3.8
Color APC units 15.0 LT 1.0
Volatile Organic Compounds
EPA Method 502.2 See attached report. None detected
Yes No WATER IS SUITABLE FOR DRINKING PURPOSES F ARAMETERS TESTED.
XXX
Date �3 9
on ld J. Saa i
IT = Less Than Laboratory DYtector
9-23-' 4 9:47 AM ;GROUNDWATER. -INALYTICAL ENVIROTEC. -U
r ,
` MASSACHUSETS.DEP/DIVISION OF WATER SUPPLY
VOLATILE ORGANIC CONTAMINANT REPORT VOC
(FORM#7.1) page 1 of 3
PWS INFORMATION:
1 PWSlD#. 2. .City/Town: Lot 4, Carlson Lane,
W. Barnstable, MA
3. PWS Name: Ed Bower
4. Sample ID#ISource Code CL 5. Sample Location: same 6. Date Collected: 7. Collected By:
09-22-94 L.Wile&Son
8. Routine: Special: = (explain below) 9. Sample: ( )Raw Water ( )Finish Water
10. Composite(or multiple)sample? (Y,N) If yes, list the multiple or composited sources:
Notes:
LABORATORY ANALYTICAL INFORMATION:
Lab Name: Groundwater Analytical, Inc. Lab Cert.#: MA103
Subcontracted? Yes^ No_ If Yes please provide name and certification*
Lab Sample ID#: 8797-01
Notes: Practical Quantltation Limit(PQL)substituted for Detection Limit.
Compound (Regulated) Result MCL POL Analytical Date
u9/L u9/L ug/L Method Analyzed
Benzene ND 5.0 0.5 502.2 09-22-94
Carbon Tetrachloride ND 5.0 0.5 502.2 09-22-94
1,1-Dichioroethylene NO 7.0 0.5 502.2 09-22-94
1,2-Dichloroethans ND 5.0 0.5 502.2 09-22-94
para-Dichlorobenzene NO 5.0 0.5 502.2 09-22-94
Trichloroethylene ND 5.0 0.5 502.2 09-22-94
1,1,1-Tdchlorcethene ND 200.0 0.5 502.2 09-22-94
Vinyl Chloride ND 2.0 0.5 502.2 09-22-94
Monochlorobenzene NO 100.0 0.5 502.2 09-22-94
o-Dichlorobenzene ND 600.0 0.5 502.2 09-22-94
trans-1,2-Dichlomethylene ND 100.0 0.5 502.2 09-22-94
cis-1,2-Dichloroethylene ND 70.0 0.5 502.2 09-22-94
1,2-Dichloropropane ND 5.0 - 0.5 502.2 09-22-94
Ethylbenzene ND 700.0 0.5 502.2 09-22-94.
Styrene ND 100.0 0.5 - 502.2 09-22-94
Tetrachloroethylene ND 5.0 0.5 502.2 09-22-94
Toluene NO 1000.0 0.5 502.2 09-22-94
Xylenes(total) ND 10000.0 0.5 502.2 09-22-94
Dichloromethane. ND 5.0 0.5 502.2 09-22-94
1,2,4-Trichlorobenzene ND 70.0 0.5 502.2 09-22-94
1,1,2-Trichloroethane NO 5.0 0.5 502.2 09-22-94
_3-91 9: a7 AM ;GROUNDWATER ANALYTICAL ENVIRCTECH `•0S 759 - _- ; M 3/ b
~k-IWS 1D#:
(FORM#7.1) Town:
Lab Sample I.D.#:8797-01 VOC
page 2 of 3
Compound(Unregulated) Result MCL PQL Analytical Date
uglL ug/L ug/L TMethod Analyzed
Chloroform NO ---- 0.5 502.2 09-22-94
Bromodichloromethane ND ---- 0.5 502.2 09.22-94
Chlorodibromomethane ND ---- 0.5 502.2 09-22-94
Bromoform NO ---- 0.5 502.2 09-22-94
m-Dichlorobenzene NO ---- 0.5 502.2 09-22-94
Dibromomethane NO ---- 0.5 502.2 09-22-94
1,1-Dichloropropane ND ---- 0.5 502.2 09-22-94
1,1-Dichloroethane NO ---- 0.5 502.2 09-22-94
1,1,2,2-Tetrachloroethane NO ---- 0.5 502.2 M22-94
1,3-Dichloropropane NO ---- 0.5 502.2 09-22-94
Chloromethane NO .... 0.5 502.2 09-22-94
Bromomethans NO ---- 0.5 502.2 09-22-94
1,2,3-Trichloropropane ND .... 0.5 502.2 09-22-94
1,1,1,2-Tetrachloroethane I NO ---- 0.5 502.2 09-22-94
Chloroethane NO ---- 0.5 502.2 09-22-94
2,2-Dichloropropane NO ---- 0.5 502.2 09-22-94
o-Chlorotoluene ND ---- 0.5 502.2 09-22-94
p-Chlorotoluene ND ---- 0.5 502.2 09-22-94
Bromobenzene ND ---- 0.5 502.2 09-22-94
1,3-Dichloropropane ND ---- 0.5 502.2 09-22-94
1,2,4-Trimethylbenzene ND ---- 0.5 502.2 09-22-94
1,2,3-Trichlorobenzene ND .... 0.5 502.2 09-22-94
n-Propylbenzene NO .... 0.5 502.2 09-22-94
n-Butylbenzene NO .... 0.5 502.2 09-22-94
Naphthalene ND ---- 0.5 502.2 09-22-94
Hexachlorobutadiene ND ---- 0.5 502.2 09-22-94
1,3,5-Trimethylbenzene NO .... 0.5 502.2 09-22-04
p-Isopropyltoluens ND ---- 0.5 502.2 09-22-94
Isopropylbenzene ND ---- 0.5 502.2 09-22-94
Tert-bu tyl benzene NO ---- 0.5 502.2 09-22-94
------------------------------------�
----------------------------------------------------------------------
9:47 ANAL`tTICAL EIQVIROTECH 503 759 4475;# 4/ 5
`40WS ID#.: (FORM 7.1) Town:
Voc
Lab Sample ID#:8797-01
page 3 of 3
Result MCL PQL Analytical Date
Compound(Regulated) ug/L ug/L Limit uglL Method Analyzed
Sec-butylbenzene ND -•-- 0.5 502.2 09-22-94
Fluorotrichloromethane ND ---- 0.6 502.2 09-22-94
Dichlorodifluoromethane ND ---- 0.5 502.2 09-22-94
Bromochloromethane ND ---- 0.5 502.2 09-22-94
Surrogate Recoveries(As required by EPA Method 524.1 and 524.2)
Compound %Recovered QC Limits(%)
Dibromofluoromethane NIA 86-118
Toluene-d8 NIA 88-110
4,-Bromofluorobenzens NIA 86-115
The QA/QC required matrix spike sample information is on file at our office.
Laboratory Director signature and date:
k!�►t•� 4.S 9•23•g�
Attention: Mail TWO copies of this report to DEP/DWS; 1 Winter Street;9th Floor,Boston MA 02108;Attention: WQA-SAMP; within 30 days of
receipt of results and no later than 10 days after the end of the reporting period.
---------------------------------------------------------------------------------------------------
FOR DEP/DWS USE ONLY:
Approved: Rejected: Other:
Date: DWS Staff:
Computer data entered:
I
TOWN OF BARNSTABLE
7
LOCATION 6®7• 4- CAI?-L.50,4-J LA, SEWAGE # 1?4- SSS
VILLAGE IJ, 15/1"57-1961-E ASSESSOR'S MAP &
INSTALLER'S NAME & PHONE NO. L9 • M'.rkrTYZe 385-940.7
SEPTIC TANK CAPACITY /rJ'00 C,19
i
LEACHING FACILITY:(type) CALLS y <�� E (size)
NO. OF BEDROOMS 5 'PRIVATE WELL OR PUBLIC WATER WELL
BUILDER OR OWNER 50W C-P—
DATE PERMIT ISSUED: 9- 2.3-If
DATE COMPLIANCE ISSUED: //- 2- 94
VARIANCE GRANTED: Yes No i/
� = 1
DGJ�LL ,
No/_!-.......
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Appliration for Mitip ottl Wor1w Tomitrnrtion rrrmit
Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
System at: _
.............................................................,07 4Sor/ G•�nC�
................................� X
......_-1 _......................... ...__..
. Address
u�. A L wn e -----------------
Owner -.-•-----!*��
............... -- ---------------•-------------- - -------------1
Address
--------------------------------------------------------------------------------- •---
Installer Address ��J� /
Type of Building Size Lot____._..•____________.....Sq. feet
U Dwelling—No. of Bedrooms--------------------------------- -----Expansion Attic (vo Garbage Grinder ( )
` ___. No. of ersons---------------------------- Showers — Cafeteria p,, Other—Type of Building p ( ) ( )
Other fixtures �QtiDoyte+o--------------------------------------------------------------------------•--•---------------...........
W Design Flow--------------------------------------------gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity............gallons Length________________ Width................ Diameter---------------- Depth................
x Disposal Trench—No- -------------------- Width-------------------- Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No..-_-_-_.--_-----._ Diameter-_--.--_-.._-_-.-- Depth below inlet.................... Total leaching area..................sq. ft.
z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by-------------------------------------------------------------------------- Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit-------_---__.___._. Depth to ground water.........................
(i Test Pit No. 2................minutes per inch Depth of Test Pit-_--_---..______-__- Depth to ground water........................
0 Description of Soil................ <<D__WIXU............ ?7------------- . 96>7
V .-------------------------------------------------------•-----------•-------------------.............-------------------------------------•-------------•-----------•----------•-------•--------........
W
UNature 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 undersigned further agrees not to place the
system in operation until a Certificate of Compliance has been issued by the board of health.
Signed ---------------------------------------------------------------------- ----------------------------------- .................................:......
Application Approved BY61 /v-.. `�- et�"� ���------------- --------------------------------------------------------------- Dare
Application Disapproved for the following reasons: ..................................... ..
-
toPermit No. 7 ----------.
ii Daze
No....
' THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Appliratiun for Di-ripuuttl Work.6 Tunutrnrtiun f unlit
Application is hereby made for a Permit to Construct (X) or Repair ( ) an Individual Sewage Disposal
System at:
............................................
...
.........................................
-• • . - -- — .- - - �. . ._. --
��., L %Fa •Address
GG+P/ +� � /2GSCJ 17 G i cIJ• i[fsT}? �
or t o. ............... '
Ow ner r Address
Installer — AddressPQ
/U Type of Building Size Lot.......:.:.............. ...Sq. feet
.� Dwelling—No. of 4—
Attic (OC}' Garbage Grinder ( )
04 Other—Type of Building .) 94,'"_'�.'�. ..... No. of persons----------------_-____---- Showers ( ) — Cafeteria ( )
114
Other fixtures . ��SiDPs--�-------------------------------------------- ----------------------------------------------•-••••'.------
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity------------gallons Length---------------- Width---------------- Diameter................ Depth................
x Disposal Trench—No. .................... Width-------------------- Total Length-------------------- Total leaching area....................sq. ft.
Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. 1----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water........................
fi, Test Pit No. 2................minutes per inch Depth of Test Pit-------- ........... Depth to ground water........................
p+' -------,,-r'�•...........................................................................................................................
72
D Description of Soil----------------17 CCG- /�' ' ------•-••• `V-----...;0_---•-- --•- --------''- �7....
U ..............................................-•-•-••-•••-•----•--•••-•••••----'•-•--------•--•-----'---•••••---•----------------'---'-•-••---------...-••••••------'-•••'--•'-••--••-••"-'-'---•....'-
W
-•---•-----------------'---------......-•--------------------•-----•----------------•-----------------------•-------------------•---------•---------------------------•--••--••-••----•--•-•---•......
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 undersigned further agrees not to place the
system in operation until a Certificate of Compliance has been issued by the board of health.
Signed ------------------------------------------------------------------------------------------------------- a- L
Application Approved By _
--'-- -----...------ --�-------........................................'------- Date
Application Disapproved for the following reasons: -- -------------------------- --------------------I..................................
.............................................................•- . . ....................... ... ..................................................-................... ---------- --------------------
re
Permit No. ......... � '' --� � Issued ...........................�.�.. .....- -------
Date
----------------------- -------------------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
C'I.ex#ificazte of (111ompliaxn e
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
b7/1.Pi� . r� " ` ` `/Ty`r�`---��° ------------------------ ------------------------------------------------------------------------------------------------------
Y -------------- X
InscaOerat ....... ..7........... L. ../............................... r4, etr 7`h3L------------------------------------------------
has been installed in accordance with the provisions of TITLEJ of The State Environmental Code as described in
the application for Disposal Works Construction Permit No. y ..... �„a- ... dated .�._� .��..�" .�....��-
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE....... ./-.-c�:...... ... /..... _............._---------- Inspectors ._....... .................................................
-----,_c-,---------------------------------------------------------i----_
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
No....... ................ FEE---• -
�i��rn�ttl urk� �an�trii�nrrutit
Permission,i�s.hereby granted-------- ,. `�1�.'C' " /' -�" .'....................-.....................
to Construct (( ) or Re air ( ) an IndividualeSewage Disposal Sys
atNo..--•-.-ter v,.-7.----._.._. .�1, -. .._..,el/i C '...-...... � ... ----- ---- _:,'....................
as shown on the application for Disposal Works Construction P�-it - _ Dated..... -" ..�W'-r...'7..'"_.f��
Board of Health
DATE.------. ......................... ------
FORM 36508 HOBBS A WARREN.INC..PUBLISHERS
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