HomeMy WebLinkAbout0120 COACHMAN LANE - Health LVW
20 Coachman Lane
. Barnstable P
= 151 028100
- c
t
�ECE'VED
COMMONWEALTH OF MASSACHUSETTS SE
1 0 2002
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTI TOWN O HEALTH BARNSTABLE
--
h M
j ' d
t
ti
4
3; t
` TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSU`RFACESEWAGE DISPOSAL SYSTEM FORM
PART A
r CERTIFICATION
Property Address: 120 COACHMAN LANE WEST BARNSTABLE, MA 02668 "JW
Owner's Name: JOHN LEE ;
Owner's Address: 120 COACHMAN LANE WEST BARNSTABLE, MA 02668
Date of Inspection: 8/26/02
Name of Inspector: (please print); JOHN GRACI
Company Name: SEPTIC INSPECTIONS�(
Mailing Address: \P.O. BOX 2119 TEATICKET, MA.02536
Telephone Number: 508-564-6813 FAX 508'-564-7270
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is
true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and
experience in the proper function aiid,maintenance of on site sewage disposal systems. I am a DEP approved system
inspector pursuant to Section 15340 of Title 5(310 CMR 15.000). The system:
Y
X Passes
Conditio'nall'y P• es
_ Needs Further, aluation by the Local Approving Authority
Fails
Inspector's Signature: Datc: 8/26/02
The system inspector shall submit a c y of this inspection report to the Approving Authority(Board of Health or DEP)within
is a shared system or has a design flow of 10,000 gpd or greater,the
30 days of completing this inspection. If the system Y
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 scent to the buyer, if applicable,and the approving authority.
� y
Notes and Comments
SYSTEM PASSED TITLE V INSPECTION. RECOMMEND PUMPING NOW AND THEN EVERY TWO YEARS TO
PROLONG THE SYSTEMS USEFUL LIFE.
****This report only describes confliticas at the time of inspection and ullticl till'l'llntll(")lls Ilf'Ise III (I1111 Illlle.This
inspection does not address how the system will perform in the future under the same or different conditions of use.
`'v 2
4.
TItIP r, Tncnrrtinn Form
Page 2 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 120 COACHMAN LANE WEST BARNSTABLE, MA 02668
Owner: JOHN LEE
Date of Inspection: 8/26/02
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
X I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310
CMR 45.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
SYSTEM PASSED TITLE'V INSPECTION. RECOMMEND PUMPING NOW AND THEN EVERY TWO YEARS
TO PROLONG THE SYSTEM'S USEFUL LIFE.
B. System Conditionally Passes:
_ One or more system componetimas described in the"Conditional Pass"section need to be replaced or repaired.The system,
upon completion of the replacenvent,orj pair,as approved by the Board of Health,will pass.
Answer yes,no or not determined;(Y,N,ND) iniihe for the following statements. If"not determined"please explain.
n/a The septic tank is metal and over26ye6rs old* or the septic tank(whether metal or not) is structurally unsound,exhibits
substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced
with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating
that the tank is less than 20 years old is available.
ND explain: n/a
n/a Observation of sewage backup"or.break out or high static water level in the distribution box due to broken or obstructed
pipe(s)or due to a broken,settle&or uneven distribution box. System will pass inspection if(with approval of Board of
Health):
_ broken pipe(s)are replaced
obstruction is removed
distrib'ut6 box is leveled or replaced
ND explain: n/a
'hit .�
n/a The system required pumping°mor'e'than 41imes a year due to broken or obstructed pipe(s). The system will pass
inspection if(with approval of the Board of Health):
_broken,pi,pe(s)are replaced
_olis'truction is removed
ND explain: n/a
Page 3 of 11
OFFICIAL INSPECTION.FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 120 COACHMAN LANE WEST BARNSTABLE, MA 02668
Owner: JOHN LEE
Date of Inspection: 8/26/02
C. Further Evaluation is Required by the'Board of Health:
_ Conditions exist which require further evaluation by the Board of Health in ord'--r to determine if the system is failing to
protect public health,safety or the environment.
1. System will pass unless Boaril'of Health determines in accordance with310 CMR 15.303(l)(b)that the system is
not functioning in a manner which will protect public health,safety and the environment:
, a
x
_ Cesspool or privy is wi6n°56 feef 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 septid tank and SASI'and the SAS is within 50 feet of a private water supply well.
'1j
_ The system has a septic tank arid SAS and the SAS is less than 100 feet but 50 feet or more from a private water
supply well". Method used to'deterw.ine distance n/a
*"This system passes if the well°water analysis,performed at a DEP certifies 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 t6'or less than 5 ppm,provided that no other failure criteria are triggered. A copy
of the analysis must be aitached fo_this form.
,
3. Other:
f
a.
.tie 'y i
r
�t
Page 4 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 120 COACHMAN LANE WEST BARNSTABLE, MA 02668
Owner: JOHN LEE
Date of Inspection: 8/26/02
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each,of the following for alLinspections:
Yes No
X Backup of sewage into facility,or system component due to overloaded or clogged SAS or cesspool
X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged
SAS or cesspool i ,
X Static liquid level in the,distribution,box above outlet invert due to an overloaded or clogged SAS or cesspool
X Liquid depth in cesspool is less than 6"below invert or available volume is less than ''/z day flow
X Required pumping,more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times
pumped 2 YEARS BY OWNER`.`
X Any portion of the SAS,cesspool or privy is below high ground water elevation.
X Any portion of cesspool:or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
X Any portion of a cesspool or privy is within a Zone 1 of a public well.
X Any portion of a cesspool or privy is within 50 feet of a private water supply well.
X Any portion of a cesspool.or privy is,less than 100 feet but greater than 50 feet from a private water supply well with
no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP
certified laboratory, foi,coli.form 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.Iq
(Yes/No)The system fails. 11 have determined that one or more of the above failure criteria exist as described in 310
CMR 15.303,therefore the system•fail?.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 now of 10,000 gpd to 15,000 gpd.
You must indicate either"yes"or ,no,,to each of the following:
(The following criteria apply to Large sysiems'in addition to the criteria above)
yes no
X the system is within 400 feet of a surface drinking water supply
X the system is within 206 feet df a tributary to a surface drinking water supply
A
X the system is located in{'a'nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped
Zone 11 of a public water'sup'ply well
If you have answered"yes",,to any question in Section E the system is considered a significant threat,or answered
eft +4 <<p
oullon D lbove.Ih� I f ti)' tEin ho failed: ThC 0�'i'ITI Pf ohero(nr of any I r e 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 ofa ce of the Department.
{` d
r +
Page 5 of 1 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM 11'ISPECTION FORM
PART B
CHECKLIST
Property Address: 120 COACHMAN LANE WEST BARNSTABLE, MA 02668
Owner: JOHN LEE
Date of Inspection: 8/26/02
Check if the following have been done. You must indicate"yes" or"no" as to each of the following:
Yes No
X _ Pumping information was provided by the owner,occupant,or Board of Health
X Were any of the system.components,pumped out in the previous two weeks?
X _ Has the system received normal flows in the previous two week period?
X Have large volumes ofwater'been introduced to the system recently or as part of this inspection `?
X _ Were as built plans of the system obtained and examined?(If they were not available note as N/A)
X _ Was the facility or dwelling,ins'ected for signs of sewage back up?
X _ Was the site inspected for signs of break out`?
X _ Were all system components,excluding the SAS, located on site
X _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the
baffles or tees, material of construction,dimensions,depth of liquid,depth of sludge and depth of scum ?
X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance
of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS)on the site has been determined based on:
Yes no '
X _ Existing information.`For example, a plan at the Board of Health.
X _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is
unacceptable)[310 CMR 15.302(3)(b))
A
i tl, r
i 51
r
Page 6 of I I
t c
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 120 COACHMAN LANE WEST BARNSTABLE, MA 02668
Owner: JOHN LEE
Date of Inspection: 8/26/02
° tt `' ELOW'CONDITIONS
RESIDENTIAL
Number of bedrooms(design):3 1 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15'203 (for example: 1 10 gpd x#of bedrooms): 330
Number of current residents: 2
Does residence have a garbage grinder;(yes or no): NO
Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required]
Laundry system inspected(yes or no) NO
Seasonal use: (yes or no): NO
Water meter readings, if available(last 2 years usage(gpd)): n/a
Sump pump(yes or no): NO
Last date of occupancy: n/a
COMMERCIAL/INDUSTRIAL
Type of establishment: n/a
Design flow(based on 310 CMR 15.203): n/agpd
Basis of design flow(se ats/persons/sgft,etc.): n/a
Grease trap present(yes or no): NO
Industrial waste holding tank present(yes or no): NO
Non-sanitary waste discharged to:'the Title 5 system(yes or no): NO
Water meter readings, if available: n/a
Last date of occupancy/use: n/a
OTHER of
n/a
�., GENERAL INFORMATION
Pumping Records ,,
Source of information: 2 YEARS BY OWNER
Was system pumped as part of the inspection(yes or no): NO
If yes,volume pumped: n/agallons-- How was quantity pumped determined? n/a
Reason for pumping: n/a
TYPE OF SYSTEM
X Septic tank,distribution box,soil absorption system
_Single cesspool
_Overflow cesspool
_Privy
_Shared system(yes or no)(if yes,attach previous inspection records, if any)
_Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from
system owner)
_Tight tank Attach a copy of the DEP approval
Other(describe): n/a
,
Approximate age of all componeri 'date ins[alled(if known)and source of information:
13 116 111' OWNER
Were sewage odors detected when arriving at`the site(yes or no): NO
A
Page 7 of l 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE fSEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 120 COACHMAN LANE WEST BARNSTABLE,MA 02668
Owner: JOHN LEE
Date of Inspection: 8/26/02
BUILDING SEWER(locate on site plan)
Depth below grade: 20"
Materials of construction:_cast iron X40.PVC_other(explain): n/a
Distance from private water supply well or suction line: n/a
Comments(on condition of joints,'venting,evidence of leakage,etc.):
WELL WATER
SEPTIC TANK: X(locate on site plan)
Depth below grade: 14"
Material of construction: Xconcrete metal_fiberglass_polyethylene other(explain)n/a
If tank is metal list age: n/a Is age'eodfirnied by a Certificate of Compliance(yes or no): NO(attach a copy of certificate)
Dimensions: 1000G L 8' 6" H 5' 7 W'4' 1011"
Sludge depth:3"
Distance from top of sludge to bottom of owlet tee or baffle: 31"
Scum thickness:3"
Distance from top of scum to top of.outlet tee.or baffle: 6"
Distance from bottom of scum to bottom of outlet tee or baffle: 15"
How were dimensions determined: MEASURED
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related
to outlet invert,evidence of leakage,etc.):
SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY.
RECOMMEND PUMPING NOW AND THEN EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL
LIFE.
GREASE TRAP:_(locate on site plan)
Depth below grade: n/a
Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a
Dimensions: n/a
Scum thickness: n/a
Distance from top of scum to top of outlet tee or baffle: n/a
Distance from bottom of scum to bottom of outlet tee-or baffle: n/a
Date of last pumping: n/a
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related
to outlet invert,evidence of leakage,etc.):
n/a ,
,
µf
7
s
Page 8 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 120 COACHMAN LANE WEST BARNSTABLE,MA 02668
Owner: JOHN LEE
Date of Inspection: 8/26/02
TIGHT or HOLDING TANK: +(tank must be pumped at time of inspection)(locate on site plan)
Depth below grade: n/a
Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a
Dimensions: n/a
Capacity: n/a gallons
Design Flow: n/a gallons/day
Alarm present(yes or no): N/A
Alarm level: N/A Alarm in working order(yes or no): NO
Date of last pumping: n/a `
Comments(condition of alarm and float switches, etc.):
n/a
DISTRIBUTION BOX:X(if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into
or out of box,etc.):
D-BOX WAS VIDEO INSPECTED AND APPEARS TO BE STRUCTURALLY SOUND. RECOMMEND RAISING
COVER.
PUMP CHAMBER: _(locate on site plan)
Pumps in working order(yes o-no): NO
Alarms in working order(yes or no):NO
Comments(note condition of pump chamber,'condition of pumps and appurtenances,etc.):
n/a .
I1 `•
Page 9 of I l
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 120 COACHMAN LANE WEST BARNSTABLE,MA 02668
Owner: JOHN LEE
Date of Inspection: 8/26/02
SOIL ABSORPTION SYSTEM (SAS): X (locate on site plan,excavation nji required)
If SAS not located explain why:
n/a.
Type
1000 GAL 6' X 6' leaching pits, number: 1
n/a leaching chambers, number: n/a
n/a leaching galleries, number: n/a
n/a leaching trenches, number, length: nla
n/a leaching fields, number: n/a
n/a overflow cesspool, number: n/a
n/a ;., innovative/alternative system
z Type/name of technology: n/a
Comments(note condition of soil;signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.):
DID NOT EXPOSE LEACH PIT. APPEARS TO BE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY.
SYSTEM SHOWS NO SIGNS OF FAILURE. RECOMMEND RAISING COVER.
CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration: n/a
Depth—top of liquid to inlet invert: n/a
Depth of solids layer: n/a
Depth of scum layer: n/a
Dimensions of cesspool: n/a
Materials of construction: n/a
Indication of groundwater inflow(yes or no): NO
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
n/a
PRIVY: (locate on site plan) s
Materials of construction: n/a' `
Dimensions: n/a
Depth of solids: n/a
Comments(note condition of soil,signs:of.hydraulic failure, level of ponding,condition of vegetation,etc.):
n/a
r
Q
Page 10 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
`SYSTEM INFORMATION(continued)
Property Address: 120 COACHMAN LANE WEST BARNSTABLE,MA 02668
Owner: JOHN LEE
Date of Inspection: 8/26/02
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.
NT
AA L
A -6 T2
s,
b/k 3 y
in
' Page 11 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property BARNSTABLE
ert Address: 120 COACHMAN LANE WEST ,
MA 02668
Owner: JOHN LEE
Date of Inspection: 8/26/02
SITE EXAM
_Slope
_Surface water
_Check cellar
Shallow wells
Estimated depth to ground water 12+feet
Please indicate(check)all methods used to determine the high ground water elevation:
NO Obtained from system design pians on record- If checked,date of design plan reviewed: n/a
YES Observed site(abutting proper y/observation hole within 150 feet of SAS)
NO Checked with local Board of Health-explain: n/a
NO Checked with local excavators, installers-(attach documentation)
NO Accessed USGS database-exp'aid: n/a
You must describe how you established the Nigh ground water elevation:
HAND AUGER- 12+FT.
}
i
tI
A ��
j
r
pry® J.
/ M.
FOR DATE l IME k '
M
PHONED
OF RETURNED
YOUR CALL
PHONE
AREA CODE NUMBER EXTENSION PLEASE CALL
MESSAGE WILL CALL
AGAIN
CA E 0
U
,` ANTS 70
(j SEE YOU
SIGNED niVerSCII. 48003
. V
No. �1 - Fee ��`ZS
BOARD OF HEALTH
TOWN OF BARNSTABLE
. ���rication,�'or�eYY �ot��truction�ermit ,
Application is hereby made for a permit to Construct (Alter ( ), or Repair ( )an individual Well at:
--���rlii7��+., .�.,_tI•Il� eY;Pilfl- /< ---------
Location — Address Assessors Map and Parcel
-------------------------------------------—-------------------------------------- ----------------------------------------------------------------------------------------
Owner Address
Installer — Driller Address
Type of Building
Dwelling� Yq!2 ----------------------------------------
Other - Type of Building---------------------------------- No. of Persons------------------------------------------------
Pu ose of Well---�------ ---------s�-- -----------------------------------•--------------------
Type of Well-y�� Pf/ - — - = Capacity--------------------
I p A?A`> ti,.n arc P ,Y---
-- ---------------
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 --------G��2���
date
4
Application Disapproved for the following reasons:--------------------------------------------------------------------------—_--------------______-----------
------ -----------------------------------------------------------------------------------------------------------------------
date
Permit No.-- --��_�c - __
-- -------- Issued - -- - - -
date
MAP
BOARD OF HEALTH PARCH O
TOWN OF BARNSTABLIET
Certificate ®f Compliance
THIS IS TO CERTIFY, That the Individual TWe11 C n'structed (� Altered ( ), or Repaired ( )
by-- -� '= - 1��' -��- ✓ /�_/�L C/�`t_L_ e _ � ---------------—- - -
Installer//
--------------------------------------------------------------
has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Prot tion
Regulation as described in the application for Well Construction Permit No. - --cry�¢ ------
Dated----
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL
SYSTEM WILL FUNCTION SATISFACTORY.
DATE-----------------------------------------------------------
-------------- Inspector-----------—---------------------------------------------------------------
ri
r
No.-j-- -----��t---- Fee -- ----
PgAR,;L OF HEALTH
TOWN OF'-BARNSTABLE
AppricationArlVell Cm5tructionpermit
Application is hereby made for a permit to Construct"(�Alter ( ), or Repair ( )an individual Well at:
x/121710 All /
—--—— — ------—----—------------—---—--------------------------------------------------------------
Location — Address t - Assessors Map and Parcel
�
-- --- —--- =—---- -- ==—— — -� -----------------------------—---------------------------------------------------
Owner s +' ?' Address
---------------—------------—-------—----—----—------------------------------------
f� Installer — Driller Address
Type bf.Building i
Dwelling/ a� --------------
f Other - Type of Building ------------------ t No. of Persons--------------------------------------------------------
Type of Well 21 P""—- - - -- - -- Capacity ------------------------------------ �.
Purpose of Well_ ----------------
Agreement:
The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The
Town of Barnstable Board of Health Private Well Protection Regulation - The undersigned further agrees not to
place the well in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed - � --'------------------ - ------ _ 7--
date
Application Approved By
- ------- ---- - - ---------------
-----------
date
Application Disapproved for the following reasons:---_-_-__-____________________-__________________________=__-_-_____________________--_-__-______-___---__-
1., • r
-----------------------------------------------------------=---------------------------------------------------------------------------------------------------------------------
date
Permit No.- — - _-- _------------------- Issued - - - - r- --- ---------------------
date
BOARD OF HEALTH
TOWN OF BARNSTABLE
(Certificate ®f Compliance
THIS IS TO CERTIFY, That the Individua� -� - -z
Weonstructed (� Altered ( ), or Repaired ( )
by----------17 r------/.ca c� -�✓��� ` � --"1 �__/�P�y�i� - ------------------------------------------------
r Offistaller
at G L G.e C✓�h-�.a h— �"1-LV r �►Sri f ,a�`'� r�
___1______—_—____-----—_________—____—__________—___—_—_______________________
has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well rotection
Regulation as described in the application for Well Construction Permit No. A ---bate-
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL
SYSTEM WILL FUNCTION SATISFACTORY.
DATE---------------------------------------------------------------------------------- Inspector------------------------------------------------------------------------------------
BOARD OF HEALTH
Z TOWN OF BARNSTABLE
Vera(Con5tructionPermit
No. --r�-/ 9�-----1'�- Fee ' '-
Permission is hereby granted-------
to Construct Alter ( ), or Repair ( ) an Individual Well t:
No. - ----- - - - - = ---------------------------------=----------------------
Street
as shown on the application for a Well Construction Permit /
No._�'cJ-9/— -- ------------------- `� �/ ���-- —---- —-- — -- — —- Dated -
Board of Health
DATE -'� - ;/`J`�------------------------------------
TOWN OF BARNSTABLE
LOCATION 7- -7 �oA Ox, A-V,6 SEWAGE # FI"6 L 9
VILLAGE,0 ASSESSOR'S MAP LOTS
02 B
INSTALLER'S NAME & PHONE NO. 2,
'SEPTIC TANK CAPACITY 199 1 U
LEACHING FACILITYAtype) .j ;7r- (sue) x
cb
NO. OF BEDROOMS ,PRIVATE WELL OR PUBLIC WATER
0
V BUILDER OR OWNER
DATE PERMIT ISSUED:
DATE .COMPLIANCE ISSUED: 7
VARIANCE GRANTED: Yes No c/
if14
3b
L
C�AC-b
Now Q..-L9 Fizz7-7. -
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF..... . . . ...... ..
Appliration for Di4pnsal Work Tonstrnrtinn Prrutit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
... ..._.....__........ •• ---...... ... f............ ..................................................................................................
Lo tiPn-Address �...Z or o.
...� r � Qe�z'.9...........................••-•----•• _�.__. 1 ,1. �41 ............
stye....... �1!
Ownera •. •.•-• s-•--•� � '-------------------------------••-...................-•••-•--•---•-•-- r� S a-cxAddr s` ...L4 ........---
Installer Address
U Type of Building Size Lot..`}_ ✓ '..Sq. feet
,.� Dwelling—No. of Bedrooms............................................Expansion Attic (--) Garbage Grinder (---)
'� Other—Type of Building No. of persons............................ Showers
a yP g ...............•------------ P ( ) — Cafeteria ( )
Q, Other fixtures -----•-------------------------•--
W Design Flow.....U.0...............................gallons per person per day. Total daily flow.. 0............................gallons.
WSeptic Tank—Liquid capacity._.000gallons Lengthel.G..... Width`..10'.'._. Diameter.12........ Depth....G........
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 boxi�v ) Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date.....................
Test Pit No. L S.".1......minutes per inch Depth of Test Pit----I_ ......_.. Depth to ground water__)
Lt, Test Pit No. 22'r-.t.....minutes per inch Depth of Test Pit----I_e.......... Depth to ground water.____/_N/PA.....
Pa' = ------------- -- - -ft--•:-......................................
0 Description of SoiL z�:._�."1� 11_-_
.. , � �-- --- . ------2Lltli-�:...s�. .
U � 1 cis =- sS.=-mac 1�s S - ,r7 - .... ---------
U e-- -----------� ' 'l'`! --- �1o ....
.............••---.-............--------------.._..----•------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the previsions of TITS 5 of the State Sanitary Code—The undersigned further agrees not to place the syst in
operation until a Certificate of Compliance has been • su by he board oj health.
igned--------------------1 . ...... . ................... �-- ......
Application Approved By..- •-- ------. ---`------• ------ ... ® --- ...........
Date
Application Disapproved for the following reasons:..............................................................................................................
.............. ..........••------....----------•--------------------••-•Q -------•--------.......-----...__........•....------........................•----------••-•-----... ...•----•-•-
Date
Permit No. ' - -.. Issued....
...................................................
Date �J
a T
NO.:..LC...,..1:= FEB.. .... ..
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
c171,-1.........OF........ !,.0 "' J ......................
Applitation for Disposal lark C�oustratrtiun rruti#
Application is hereby made for a Permit to Construct (7)"'Or Repair ( ) an Individual Sewage Disposal
Syste�m- at:
J / /'
............................................................. •-•---...
Logation-Address or Lot No.- - —.
5I , � n -
Owner Address
a ......................... •--•-••----...---......................-------•---
Installer Address
Type of Building Size Lot............................Sq. feet
V Dwelling—No. of Bedrooms............................................Expansion Attic (--) Garbage Grinder ( ..)
pal Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
a' Other fixtures ................................. .......
W Design Flow......Q...............................gallons per person per day. Total daily flow__:.^^13............................gallons.
WSeptic Tank—Liquid capacity.ICK`.(Agallons Lengthr__`:C:'-.... Width.t.t1:'?''.._ Diameter. Z.._..... Depth...G.........
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%1�4 ) Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date........................................
l Test Pit No. 1.---"`".._.._minutes per inch Depth of Test Pit.... 2........... Depth to ground water._NA-16\-----------
Test Pit No. 2.'-.t......minutes per inch Depth of Test Pit....1. '........ Depth to ground water.---._`T'" ......
O De ription of Soi3'► :� - i ,r
W ZI_.1. ':�- ---- ::Z'� .:__ s. � , 1._ l Y ._.
U /.' ----------
, ----.-•--•......................•......--------.------......-- ..... ----- ----------- .--. -----------.. ......----
O Ce Y
Agreement
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 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.................................................................................. -
ate
Application Approved By..�....�.• •- •------------------ �j
Date
Application Disapproved for the following reasons:..............................................................................................................
••-•-•------------------------------------------••-•-•----•...-•-•--••----------------•---.............--•--------•----...-••'•-•'•-•-•-------------'------'---......-------:..--------•-...-•-•--•----
Date
PermitNo_ =...& .....GK#J........ Issued-.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
�a~ L�
......... .:...... ...........OF............................ .........................................
%Trriifiratr of TI-I tpliFaatrr
THIS I�TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by ... ......... ---•-••--•-••---•--------------•-----•-•--•----.------------•------------•-------•-•-----•------------------•--•--•-------=-----•-••----•-------------------
t Inst 11
at..... ` ..... c1��.�yY +x1 .e". ...----. ..5 -----------------------•....------------------....-------•------------...
has been installed in accordance with the provisions of TIT14 5 of The State Sanitary Code s described in the
application for Disposal Works Construction Permit No............ .. .... :.: <<�.,..r dated.... ..(-0{_�_�..............
THE ISSUANCE OF THIS CERTIFICATE SHALL N T O SY'Itt1ED AS A GUA ANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE..................... .' 9' �� ............................... Inspector....
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
llYt.ld ................
...................
........OF...............
` ....:.................................................. ..
Disposal Works T. notra ion rrmit
.. --• ..?.kwage
. ....................••------•--•--...-••-------•---......-•-...............•-----....................
Permts�ion is hereby granted.. �.._�__.. �
to Const ucti,� or Repair ( an Individual Disposal System
at No� �r = `�2r 4. ..
Street
as shown on the application for Disposal Works Construction Permit N
/ _6,61 Dated
� Q� --.-.-.-.............
..... :�':� l —-----------------------------------
oardof`Fealth
DATE..... ` • /•-•---------•-FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
Department of Environmental Management/Division o:Water Retources
;- WATER WELL}COMPL'ETION REPORT,
,« WELL�LOCATION
Address^` t7 ,R C�� ;1►K ' -=
City/Town r Y TIi3 -
G.S.Quadrangle Map '
Grid Location _
Owner �"` r.�YS r- eV -4d' 9A7,01517
• `
Address -
WELL USE , A CONSOLIDATED WELL
Domestic Q Public❑ Industrial❑ . 'Type of Water'-:bearingrRock
Other a 4.
•,. ,._ Water-bearing Zones,?
,�li 1) From -- To -
Method Drilled 1°4
•,� v ;21 From,
x=�3! From To
Date Drilled _ —
41 From:., To'
r CASING A/,� Depth to Bedrock
e o� D�amet r _ -
'Length - -
Type eG� It 'UNCONSOL'IDATED'WELL
STATIC WATER LEVE Water bearing Materials
�° TSand fine�]'`mediun ;9fcoarse.Q
Feet below land surface`• Ib _.
l 5
Date measured izt"4� `'" Gravel: fine.[:),11
medium❑ coarse
a #;
Screen-
GRAVEL P-ACK WELL A
A s Slot# "length• from to
Yes" No --
t + Split;Screen.(or 2nd screen/
7 I�,LITY TESTS MADE,.
Slgt 'length from to
WATER QU
Chemical Q Biological Depth To Bedrock _
r 4
PUMP TEST:
2. ' - 'GPM."
.Drawdown -. feet afterpumping days hours at
p °P z1"Iti ykfeet after- 'hours
How measured Recover
' L'OG of FORMATIONS'�' � COMMENTS (On well or water)
t;Materials From To f
-DRILLER.
Firm
t r• 90
Address
City -
LjV `.g Re9ration No r}d[ -
t x per ignature
t r ators
ease print firm y'* ®ARD OF, HEALTH COPY t 15M-2 84-176471
I