HomeMy WebLinkAbout0009 HEZEKIAH'S WAY - Health 9 Hezo;kiah's Way
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COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
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TITLE 5
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
_A
Property Address: 9 Hezekiah's Way e1
West Barnstable, MA 02668
Owner's Name: Paul Davis
Owner's Address: "' 3
Date of Inspection: S-eptember 8. 2004
- 7, -
Name of Inspector: (Please Print) James M. Ford c
Company Name: James M. Ford rn
Mailing Address: P.O.Box 49
Osterville,MA 02655-0049
Telephone Number: (508)862-9400
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
✓ Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: -� Date: September 13, 2004
The system inspector shall subracopyof this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP. The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving
authority.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that
time. This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page 1
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Page 2 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 9 Hezekiah's Way
West Barnstable, MA
Owner: Paul Davis
Date of Inspection: September 8, 2004
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:
.B. System Conditionally Passes:
One or more system components as described in the"Conditional Pass" section need to be replaced or
repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined",please
explain.
The septic tank is metal and over 20 years 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
i_-tdicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
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OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 9 Hezekiah's Way
West Barnstable, MA
Owner: Paul Davis
Date of Inspection: September 8, 2004
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 1.5.303(1)(b)that the
system is not functioning in a manner which will protect public health,safety and the environment:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
_ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone I of a public water supply.
The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well". Method used to determine distance
"This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other:
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Page 4 of 11
OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 9 Hezekiah's Way
West Barnstable, MA
Owner: Paul Davis
Date of Inspection: September 8, 2004
D. System Failure Criteria applicable to all systems:
You must indicate either"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
✓ 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 'h day flow
✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number
of times pumped_.
✓ Any portion of the SAS,cesspool or privy is below high ground water elevation.
✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
✓ Any portion of a cesspool or privy is within a Zone 1 of a public well.
✓ Any portion of a cesspool or privy is within 50 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 coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria
are triggered. A copy of the analysis must be attached to this form.]
No (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large System:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd.
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
Yes No
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.
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Page 5 of 11
OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: _ 9 Hezekiah's Way
West Barnstable, MA
Owner: Paul Davis
Date of Inspection: September 8, 2004
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:
Yes No
✓ _ 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 CNM 15.302(3)(b)].
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OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 9 Hezekiah's Way
West Barnstable, MA
Owner: Paul Davis
Date of Inspection: September 8, 2004
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#or bedrooms): 330
Number of current residents: 3
Does residence have a garbage grinder(yes or no): n/a
Is laundry on a separate sewage system(yes or no): n/a [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)): Private well
Sump Pump(yes or no): No
Last date of occupancy: Currently occupied
COMMERCIALANDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): end
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):
industrial waste holding tank present(yes or no)
Non-sanitary waste discharged to the Title 5 system(yes or no):
Water meter readings, if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: Pumped 2 years ago-per owner
Was system pumped as part of the inspection(yes or no): No
I 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)
Tight Tank Attach a copy of the DEP approval
Other(describe):
Approximate age of all components,date installed(if known)and source of information:
Installed 5126195-per as built card
Were sewage odors detected when arriving at the site(yes or no): No
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Page 7 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 9 Kezekiah's Way
West Barnstable, MA
Owner: Paul Davis
Date of Inspection: September 8, 2004
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials of construction: _cast iron _40 PVC other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK: ✓ (locate on site plan)
Depth below grade: 12"
Material of construction: ✓ concrete _metal _fiberglass _polyethylene
_other(explain)
If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of
certificate)
Dimensions: 1500 gal.
Sludge depth: 2"
Distance from top of sludge to bottom of outlet tee or baffle: 30"
Scum thickness: 4"
Distance from top of scum to top of outlet tee or baffle: 6"
Distance from bottom of scum to bottom of outlet tee or baffle: 12"
How were dimensions determined: Measuring stick
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
Cement tees were present. The liquid level was even with the outlet invert. There did not appear to be any signs of leakage.
GREASE TRAP: None (locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _fiberglass _polyethylene _other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
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Page 8 of 11
OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 9 Hezekiah's Way
West Barnstable, MA
Owner: Paul Davis
Date of Inspection: September 8, 2004
TIGHT or HOLDING TANK: None (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/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: Even
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.):
The_D-box was clean. No solids were present.
PUMP CHAMBER: None (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no)
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
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Page 9 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 9 Hezekiah's Wav
_West Barnstable, MA
Owner: Paul Davis
Date of Inspection: September 8, 2004
SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required)
If SAS not located explain why:
Type
✓ leaching pits,number: 1 - T 0000 gal.) low profile-per as built card
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.):
There did not appear to be any signs of backup or failure
CESSPOOLS: None (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 or no):
Comments (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
PRIVY: None (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.):
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Page 10 of 11
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 9 Hezekiah's Way
West Barnstable, MA
Owner: Paul Davis
Date of Inspection: September 8. 2004
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.
as
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Page 11 of 11
OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 9 Hezekiah's Way
West Barnstable, MA
Owner: Paul Davis
Date of Inspection: September 8, 2004
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 50 + feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
_ Observed site(abutting property/observation hole within 150 feet of SAS)
✓ Checked with local Board of Health-explain: topographic and water contours maps
Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Using Barnstable topographic maps and water contours maps the maps were showing approximately 50'+ to ground water
at this site.
This report has been prepared and the system inspected and passed as of the date of inspection. This report is
not a warranty or guarantee that the system will function properly in the future. There have been no warranties
or guarantees, either expressed, written or implied, relating to the system, the inspection and/or this report.
11
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CERTIFICATE OF ANALYSIS
gip:. r a.•..
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Barnstable County Health Laboratory -----
yrr Chu-Y^/ .__.�......- - -
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Report Dated: 9/I2/2005
Report Prepared For: 1
Order No.: 1 L53 �9P 14 2005 I
Victor Tagliaferro tt
39 Gilmore Road '-q':..
Belmont, MA 02478
Laboratory ID#: 0532959-01 Description: Water-Drinking Water
Sample#: 32959 Sampling Location 9 Hezekiahs Way,W. Barnstable,MA Collected: 9/2/2005
Collected by: V.T. Received: 9/2/2005
EPA 524.2- Volatile Organics by GC/MS
!TEM RESULT UNITS RL MCL Method 4 Tested
LAB: GC/MS
1,1,1,2-Tetrachloroethane BRL ug/L 0.5 EPA 524.2 9/8/2005
1,1,1-Trichloroethane BRL . ug/L 0.5 200 EPA 524.2 9/8/2005
1,1,2,2-Tetrachloroethane BRL ug/L 0.5 EPA 524.2 9/8/2005
1,1,2-Trichloroethane BRL ug/L 0.5 5.0 EPA 524.2 9/8/2005
1,1,7Dichloroethane BRL ug/L 0.5 EPA 524.2 9/8/2005
111-,Dichloroethene, BRL ug/L 0.5 7.0 EPA 524.2 9/8/2005
1,1-Dichloropro.pene BRL ug/L 0.5 EPA 524.2 9/8/2005
1,2,3-T rich lorobenzene BRL ug/L 0.5 EPA 524.2 9/8/2005
1,2,3-Trichloropropane BRL ug/L 0.5 EPA 524.2 9/8/2005
1,2,4-Trichlorobenzene BRL ug/L 0.5 70 EPA 5242 9/8/2005
1,2,4-T rim ethylbenzene BRL ug/L 0.5 EPA 524.2 9/8/2005
1,2-Dibromo-3-chloropropa BRL ug/L 0.5 EPA 524.2 9/8/2005
1,2-Dibromoethane (EDB) BRL ug/L 0.5 EPA 524.2 9/8/2005
1,2-Dichlorobenzene BRL ug/L 0.5 600 EPA 524.2 9/8/2005
1,2-Dichloroethane BRL ug/L 0.5 5.0 EPA 524.2 9/8/2005
1,2-Dichloropropane BRL ug/L 0.5 EPA 524.2 9/8/2005
1,3,5-Trim ethyl benzene BRL ug/L 0.5 EPA 524.2 9/8/2005
1,3-Dichlorobenzene BRL ug/L 0.5 EPA 524.2 9/8/M05
1,3-Dichloro ,ropane BRL ug/L 0.5 EPA 524.2 9/8/2005
I1,4.-Dichlorobenzene BRL ug/L 0.5 5.0 EPA 524.2 9/8/2005
' 2,2-Dichloropropane BRL ug/L 0.5 EPA 524.2 9/842005 i!
2-Chlorotoluene. . BRL ug/L 0.5 EPA 524.2 9/8/2005
4-Chlorotoluene BRL ug/L 0.5 EPA 524.2 9/8/2005
RL = Reporting Limit
MCL=Maximum Contaminant Level
Superior Court House, PO.Box 427, Barnstable, MA 02630 Ph: 508-375-6605
a �M Page. z
CERTIFICATE OF ANALYSIS
X, Barnstable County Health Laboratory
Report Dated: 9/12/2005
Report Prepared For:
Order No.: G0532959
Victor Tagliaferro
39 Gilmore Road
Belmont, MA 02478
Benzene BRL ug/L 0.5 5.0 EPA 524.2 9/8/2005
Bromobenzene BRL ug/L 0.5 EPA 524.2 9/8/2005
Bromochloromethane BRL ug/L 0.5 EPA 524.2 9/8/2005
Bromodichloromethane BRL ug/L 0.5 EPA 524.2 9/8/2005
Bromoform BRL ug/L 0.5 EPA 524.2 9/8/2005
Bromomethane BRL ug/L 0.5 EPA 524.2 9/8/2005
Carbon tetrachloride BRL ug/L 0.5 5.0 EPA 524.2 9/8/2005
Chlorobenzene BRL ug/L 0.5 100 EPA 524.2 9/8/2005
Chloroethane BRL ug/L 0.5 EPA 524.2 9/8/2005
Chloroform 2.0 ug/L 0.5 EPA 524.2 9/8/2005
Chloromethane BRL ug/L 0.5 EPA 524.2 9/8/2005
cis-1,2-Dichloroethene BRL ug/L 0.5 70 EPA 524.2 9/8/2005
cis-1,3-Dichloropropene BRL ug/L 0.5 EPA 524.2 9/8/2005
Dibromochloromethane BRL ug/L 0.5 EPA 524.2 9/8/2005
Dibromomethane BRL ug/L 0.5 EPA 524.2 9/8/2005
Dichlorodifluoromethane BRL ug/L 0.5 EPA 524.2 9/8/2005
Ethylbenzene BRL ug/L 0.5 700 EPA 524.2 9/8/2005
Hexachlorobutadiene BRL ug/L 0.5 EPA 524.2 9/8/2005
Isopropylbenzene BRL ug/L 0.5 EPA 524.2 9/8/2005
Methyl-tert-butyl ether BRL ug/L 0.5 EPA 524.2 9/8/2005
Methylene chloride BRL ug/L 0.5 5.0 EPA 524.2 9/8/2005
n-Butylbenzene BRL ug/L 0.5 EPA 524.2 9/8/2005
n-Propylbenzene BRL ug/L 0.5 EPA 524.2 9/8/2005
Naphthalene BRL ug/L 0.5 EPA 524.2 9/8/2005
p-Isopropyltoluene BRL ug/L 0.5 EPA 524.2 9/8/2005
sec-Butylbenzene BRL ug/L 0.5 EPA 524.2 9/8/2005
Styrene BRL ug/L 0.5 100 EPA 524.2 9/8/2005
tert-Butylbenzene BRL ug/L 0.5 EPA 524.2 9/8/2005
Tetrachloroethene BRL ug/L 0.5 5.0 EPA 524.2 9/8/2005
RL = Reporting Limit
MCL=Maximum Contaminant Level
Superior Court House, PO. Box 427, Barnstable, MA 02630 Ph: 50&375-6605
c: CERTIFICATE OF ANALYSIS Page: 3
Barnstable County Health Laboratory
Report Dated: 9/12/2005
Report Prepared For:
Order No.: G0532959
Victor Tagliaferro
39 Gilmore Road
Belmont, MA 02478
Toluene BRL ug/L 0.5 1000 EPA 524.2 9/8/2005
Total xylenes BRL ug/L 0.5 10000 EPA 524.2 9/8/2005
trans-1,2-Dichloroethene BRL ug/L 0.5 100 EPA 524.2 9/8/2005
trans-1,3-Dichloropropene BRL ug/L 0.5 EPA 524.2 9/8/2005
Trichloroethene BRL ug/L 0.5 5.0 EPA 524.2 9/8/2005
TrichIorofluoromethane BRL ug/L 0.5 EPA 524.2 9/8/2005
Vinyl chloride BRL ug/L 0.5 2.0 EPA 524.2 _ — 9/8/2005
Water sample meets the recommended limits for drinking water of all the above tested parameters.
Approved By-
(Lab rector)
RL = Reporting Limit
MCL=Maximum Contaminant Level
Superior Court House, PO.Box 427, Barnstable, MA 02630 Ph: 508-375-6605
TOWN OF BARNSTABLE
LG�"ATION I-�e2e kf'4. Ld SEWAGE #
VILLAG -ASSESSOR'S MAP & LOTO ®I
INSTALLER'S NAME&PHONE NO.
SsPTIC TANK CAPACITY SW
LEACHING FACILITY: (type) �' GAL (size) tOW 140f'(�
NO.OF BEDROOMS_ '�
BUILDER OR OWNER IJ PwI AVIS
PERMTTDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leacing facility) //�� J Feet
Furnished by �/1A�GX, 1"0l
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THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH �
TOWN OF BARNSTABLE
, pphrativit for Diripinial Works Tomitrnrtiun ramit
Application is hereby made for a 3 er n lit nst ict .� or Repair ( ) an Individual Sewage Disposal
System at: (CC/ d l .
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Address v
d Type of Building Size Lot. ,-�?S .......Sq. feet
Dwelling—No. of Bedrooms................. ..................___._Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building .._._...................... No. of persons............................ Showers ( ) — Cafeteria ( )
d Other fixtures ------------------------------------------------------
W Design Flow...............................S s...---_gallons per person per day. Total daily flow...�.�._......................._...gallons.
94 Septic Tank—Liquid capacityl.I"4v0.galIons Lengtli__h� " Width. Diameter._._ Depth_4.=.C...
Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No--------./..--------- Diameter-----L..a....... Depth below inlet....... Total leaching area...Z_`t ....sq. ft.
z Other Distribution box ( ✓) Dosing tank ( )
'~ Perco'ation Test Results Performed ------6 ................................... Date_&'.fie...............
W.1 Test Pit No. 14tS._Z-_.minutes.per inch Depth of Test Pit---- _ '....... Depth to ground water......._.
44 Test Pit No. 2................minutes per inch Depth of Test Pit_................. Depth to ground water........................
.....---•-----------------------•--•---•--------•-•-•-•-------•-..... -----••••.......................................................
0 Description of Soil---- tom= 5 ..tv! # _� --- ---•-- ------------
V
W
x •---•--•---------------------•----------------...._..-•-........•---•-•-•---------.........-----•-••-----•---------•--------•---•-••--••---•---•-••--•••-•••••••-------•------------............._......
U Nature of Repairs or Alterations—Answer when applicable..................._.__.-____.._.._..........-_...--........_................................_..
---•-------..---•--••.....-----•--••-•----•-•••---•--•---•------•--•---••------•-----•-------------------•---•------------------•-----•-----•-•••--•- ..................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal Systems in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation untA a Certificate of CompliaAce has been issued by the board of health.
ne ... ---- ---- ...... /...... ...� /�Application Approved By ........sn.......................... d.... a�...—
Dace
Application Disapproved for the following reasons: ...... ............................................................................. .. .............. ........................
................. ................................................................................. .... .......................................................................................... ........................................
Dare
Permit No. ..... .C.'.�/r ..... Issued ..... ". �.lE�-s................
Dace
_ t
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
-
Appliratio>it for Diaipooul Mork,i Ta n-titr r#"ton Pr�tit
Application is hereby made for a Permit to C oristruct`{ or Repair ( ) an Individual Sewage Disposal
System at: �� D l� /U� �// yJ
.....-----
----------
Location.Address or Lot No.
r
............�._ v 4_- �1��---••--------------•--•---•...-----...-•----•---- •z�/__1 u. _ ......?...E
r __
owner p Address
`a ...........! 1�� �..........................� 1 ff� .............../� --•••^- ... —•---...------... ...............•----^_..... _._.....
Instal r Address
U Type of Building �y Size Lot-9 U o_.._...Sq. feet
Dwelling— No. of Bedrooms----.............
3._._-.-._-..-`-_-._....Expansion Attic ( ) Garbage Grinder ( )
G pl Other—Type of Building --------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( )
Otherfixtures --- ------------------- f------- . .............................................................
w Design Flow...............................5_s--_--gallons per person per day. Total daily ............. ..................gallons.
WSeptic Tank—Liquid capacityL!�OagalIons Length../4��r.--V..." Width..�-.&... Diameter......-.------- Depth.�-_-./:...
x Disposal Trench-- No. .................... Width.................... .Total Length.................... Total leaching area....................sq. ft.
.. Seepage Pit No........./....-.... Diameter..... Depth below inlet.. -4........... Total leaching area..- ....sq. ft.
Z Other Distribution box ( ✓) Dosing tank ( )
`~ Percolation Test,Results Performed by--- ................................`eDate. '_� c1a__..._.........
Test Pit No. 1L.o,5.5...7--minutes per inch Depth of Test pit....1...-,&'-....... Depth to ground water..-
f� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water---..................--.
0 Description of Soil--...T.��- ��` 4S��16 t s- - �E i_ sn ,s�✓�s �� .� s
x
Uw ' --------••----------•-•-----•....•-------------•-•--•-•-..............•---------.........•-----•-•-----••------•--••---•-•------•-•------•••••-•--------•-•--•------•--------------••-•-------..._.....
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 untkl a Certificate of Complia ce has been issued by the board of health. p
igned -- ---- ---- - .......!�?.......................•............ -S .....
.._... .. Date'.
Application Approved By -------------- "v`�1 - .....................................-......... U...._,... ..': ... 1�-�_
� �+ �� Dace
Application Disapproved for the following reasons: ...................................................................... - ........................... .................. .
................. .................... .................................... -- ........................-- ... . . . . ........................................ ....................... .............
Permit No. ...../... '..II ..................................: Issued ............off.-�.7.---�s Da e
.. . .........................
Date
� R
a.—.._— ------.—.— —————————— ----,—.-----.----- ——————— --.`...— —4 ;—�—._-------- --.
THE COMMONWEALTH OF MASSACHUSETTS
r
BOARD OF HEALTH /c
TOWN OF BARNSTABLE
Ter#if rate of Compliance
THIS I TO CERTIFY, That the Individual Sewage Disposal System constructed ( %< ) or Repaired ( )
:. -• }J
_.------------------------------by .............. a-------. c nstallcr
has been installed in accordance with the provisions of TITLE 5 of The State environmental Code as describedin
the application for Disposal Works,Construct' Permit No. .... . �` .l '_._............ dated ...: ..-[.`1..-'�.._....
pp P _.......:�....
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE......--------------- ..- , Inspector .............
---- ----------„_---.------•--•-•-------- ---�- -- -
-• ,--
�4
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN.OF BARNSTABLE �w v�
No........ FEE........................
�i��oottl or�� �nat,�tr�rrtion �rrmit
Permission is hereby granted. 1 ------ ..........................................
to Construct ( ) or Re air ( ) an Individual Sewa�eI Dispo al S stem
Street
as shown on the application for Disposal Works Construction Per- it No 1�5-.:./Zf Date ...........................-.............
.................
Board of Health
DATE............... �^
i
FORM 36508 HOBBS&WARREN.INC.,PUBLISHERS
gedt p� t #F-7497
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Made l 3 9 v
No wa-teh e.ncou*zt�
I
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Cobbt Cdt:n+ated J-tow 330 ��d `
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I
HnPi{,.Ji���eK//�wIVIteN,V(, " 296
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ate: Fi-g;=y�-�- S-a� Ze l7oatT o l�ec�.th , /rfrr` s'� {
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+ 1 E.
No. -- -=- - Fee- --------------
BOARD OF HEALTH
TOWN OF BARNSTABLE
Application-*rlftl Cootruct ion Permit
Application is hereby made fo a perm. t Construct (Alter ( ) or Re air ( )an di idual Well at:
___ - ____ - �-� _-
Location — Address Assessors Mk:- arcel
- - - ----------------— _t` � s - -8 7-4- ' '
9 Owner Address
� Sa,-t
- - _ -- -———— — 4v.e� =-----
Installer Driller Address —
Type of Building
Dwelling -------------------------------------------------------
Other - Type of Building---------------------------------- No. of Persons_--------------------------_-_-____
y
Type of Well—1-- ���---- - ----— -- 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.
Signed __-_ --
date
Application Approved By----`( - -------
Application Disapproved for the following reasons:— -----------------------------__—_______—__—___—_____—_
---------------------------------------- -----------------------------------------------------------------------
date
Permit No. - —--- Issued----- - - - - --- --- ------—-
date
BOARD OF HEALTH
TOWN OF BARNSTABLE
Certificate (Of (Compliance
THIS IS CERTI Y, That the Individual Well Constructed (Altered ( ), or paired ( )
b - -X- ---------------------------------------------------------------- �. - --
Installer
"at- -L-- -!g— / 5------- --4- -------
has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection
Regulation as described in the application for Well Construction Permit No. QEj-_- ___Dated---
- _-_ S
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL
SYSTEM WILL FUNCTION SATISFACTORY.
DATE------------------—— - — — -- Inspector------------------------------------- ------
)f r 't T►f�{ V.RaL 1 �11,B *11-614''
�ri3� •y�,.�L{ �w+.'r•�.p.;�`� `V ��` �� � '+A� f� ��v�+'j `YI � ��*-.3•�
v
!� _ Fee l
No. -- ,.------------
BOARD OFjHy,,E�ALTH ' ` I'V,
TOWN . OF BnARNSTABLE
Application-* ongtructionPermit
Application is hereby ma dea permit It Construct ((/(Alter ( )„ oc Repair (:: -)anj&diVidual Vyell�at:
i. Location Address'' Assessors Map aaVarcel
-------------- -- �- - ----- - - - � '-- - -- -
Owner Address
r
C
,�.- _—
`+ Installer. — Driller Address
Type of Building
q ?rDwe11-i�fg ._ -
Other - Type of Buildingt No. of Persons----.- x==- Y -- — --_-
T e of We11=--�-----L_`C--- .«. ,�...
yp ,-- - Capacity---=-----'--- --------------
Purpose of Well --- , ! - ---- ----
Agreement:--_._.<..'I. -
x ' The undersigned agrees to install,the aforedescribed individual well in accordance with the provisions of The
_-*T1o,,,of,'Barnstable Board of'Health Private We11 Protection Regulation The undersigned further agrees not to
Vz place the well in operation until Certificate .of Compliance has been issued by the Board of Health.
r Signed -- r
date
t Y'f Application Approved By—
l date
Application Disapproved for the following reasons: --- �`
_------—__ __
- 3 J
date
Permit No. - —fir `�1-------�= -------- Issued—=---------- '
date
:} BOARD OF HEALTH .
TOWN , OF BARNSTABLE
Certcfuate f to"mpriattfe
THIS IS CERTI Y, That the Individual Well Constructed (Altered.( ), or Pepaired
r
7+ Installer
k-) 'AD IV�
at Alm- W/q -- ---- - _4Y-------
has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection
Regulation as described.in the application for Well Construction Permit No. _- --Dated = --------9
i
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL
SYSTEM WILL FUNCTION SATISFACTORY.
DATE ---- -=---- —-- - --- Inspector—-------------------
,
-�r �� •�`�.. - a..e.�+.e�+gaes:r.ro r..'.r.a�.wan.ae
�-oi..{er..._w.ar.�..-ser:.a�o�.a+.s++�s.use.�s�r.�e�:.wa. m.r�a�...so'e�ur_aaei-�:c�._:wr.r �wdu_!m:.��r�'_'�"-�s•'-'s's. _
I ,
BOARD OF.HEALTH
TOWN OF BARNSTABLE
Metf Congtruct ion Permit T '
i
No. Fee 49
------------
t . '
Permission is hereby granted — - � -�------ - --- — ---=---------------------------
i to Construct Alter (� ), or Repair,( ) an Individual Well at:
No. -- - /A 1.15— 7L:_ _ 1= �1-- s—°�0— — - �- ------ �--- Street
as drown on the application for a Well Construction Permit
No. -----------W"- --- ------------- Dated- -5----------------------------- -
-- — = — — - --------------------------
Board of Health
_
DATE --�- --
Department of Environmental Managernent/Division of Water Resources
WELL COMPLETION REPORT WI-5
WELL LQCATION GEOGRAPHIC DESCRIPTION
Address--nj—1 --
N S E of
Weh) (circ e
City/Town
Well owner.
F
�Address— C Ya r;>✓1� /� S E W of
� +
/ [nil.inten(hsl (circle)
A if
Board of Health permit obtained: yes Id�J' no El //rtersecr. w/ (road)
WELL USE WELL DATA
Domesticublic❑ Industrial ❑ Total well depth ft.
Monitoring❑ Other_ Depth to bedrock ft.
� Water-bearing rock/unconsolidated material:
Method drilled
Description {�A
Date drilled
Water-bearing zones:
CASING 1) From To
Type )/ 2) From 1 ;0 To�(/h
Length —ft. Dia(.I.D.) —in. 3) From To
Length into bedrock ft.
Gravel pack well No dia.
Protective well seal: U(
Screen: r dia.
Grout-❑ Other Slot+ —length f—from/5(--to
STATIC WATER LEVEL(all wells)
Static water level below land surfaced-(t. Date
WELL TEST(production wells)
Drawdown�ft. after pumping _hr, min.Iat�_gpm
How measured—Recovery o r (t. afterhr. min.
0
LOG of FORMATIONS COMMENTS
Materials From To °�
rr
Driller
n Firm '-
�1
Address Po A . I a!'
0 City/Town
U. Oil ftA. ,
Supervising Driller'Reg.#
,JL
Xi nature.at tifAiervisingregisren+d well driller:'
Please Print firmly-. BOA OF-�HEA.LTH COPY, _ _
ENVIROTECH LABORATORIES, INC.
MA Cert. No.: M-MA 063 q,
449 Rte. 130 • Sandwich,MA 02563
(508)888-6460 ' 1-800-339-6460
FAX(508) 888-6446
CLIENT: Paul Davis LOCATION: Lot 13
Helekia's Way
W. Barnstable, MA
SAMPLE DATE: 1-19-95
COLLECTED BY: L. Wile DATE RECEIVED: 1-19-95
TIME: 1:OOAM SAMPLE I.D. : 13H
JOB TYPE: New well WELL DEPTH: 140'/91' Static
4" PVC Well
FLOW: 25 G.P.M.
RESULTS OF ANALYSIS:
Parameters Units Recommended Limit Result
Coliform bacteria/100ml (MF Method) 0 0
pH pH units 6.0-8.5 5.63
Conductance umhos/cm 500 146
Sodium mg/L 28.0 15.3
Nitrate-N mg/L 10.0 0.07
Iron mg/L 0.3 0.06
Manganese mg/L 0.05 0.007
Volatile Organics See enclosed report.
EPA 524 ug/L None detected.
COMMENTS: Low pH indicates high corrosive characteristics.
Yes No WATER IS SUITABLE FOR DRINKING POSES F PARAMETERS TESTED.
Xxx r
Date
-Roriald J. S ri
Laboratory Jirector
IT = Less Than
GROUNDWATER
ANALYTICAL
EPA METHODS 601 and 602
Volatile Organics (GC/PID/ELCD)
L.
Field ID: 13H Lab ID: 9772-01
Project: Davis/13 Helekia's Way Batch ID: VG2-0535-W
Client: Envirotech Sampled: 01-19-95
Cont/Prsv: 40mL VOA Vial/H C1 Cool Received: 01-19-95
Matrix: Aqueous Analyzed: 01-20-95
PARAMETER CONCENTRATION REPORTING LIMIT
(ug/L) (ug/L)
Dichlorodifluoromethane BRL 5
Chloromethane BRL 5
Vinyl Chloride BRL 5
Bromomethane BRL 5
Chloroethane BRL 5
Trichlorofluoromethane BRL 1
1,1-Dichloroethene BRL 1
Methylene Chloride BRL 1
trans-1,2-Dichloroethene BRL 1
1,1-Dichloroethane BRL 1
cis-1,2-Dichloroethene * BRL I
Chloroform BRL 1
1,1, 1-Trichloroethane BRL 1
Carbon Tetrachloride BRL 1*
(Benzene BRL 1
1,2-Dichloroethane BRL 1
Trichloroethene BRL 1
1,2-Dichloropropane BRL 1
3romodichloromethane BRL 1
2-Chioroethyl Vinyl Ether BRL 5
cis-1,3-Dichloropropene BRL 1
Toluene BRL 1
4.rans-1,3-Dichloropropene BRL 1
1,1,2-Trichloroethene BRL 1
Tetrachloroethene BRL 1
Dibromochloromethane BRL 1
Chlorobenzene BRL 1
Ethyl►oe+nze.ne BRL 1
/seta-and para-Xylene * BRL i
ortho-Xylene * BRL 1
Bromoform BRL 1
1.,1,2,2-Tetrachloroethane BRL 1
1,3-Dichlorobenzene BRL 1
1,4-Dichlorobenzene BRL 1
1,2-Dichlorobenzene - BRL 1
Q SURROGATE COMPOUND SPIKED MEASURED RECOVERY QC LIMITS
a,a,a-Trifluorotoluene 30 - 31 102 % 87 - 113 90
1,2-Dichloroethane-d4 30 29 97 % 83 - 117
BRL - Below Reporting Limit. * Non-target compound. Method References: Method 601 - Purgeable
Halocarbons and Method 602 - Purgeable Aromatics, 40 C.F.R. 136, Appendix A (1986).
--------- -----------------
1—'26-95 __: 0_' ^nl :GRCJSC:VATER ANALYTI CAL ENVIRQTc - 508 759 4475:x 3/- �
ENVIROTECH LABORATORIES, INC.
t MA Cert. No.: M-MA 063
449 Rte. 130 . Sandwich, MA 02563
(508)888-6460 . 1-800-339-6460
FAX(508) 888-6446
CLIENT: Paul Davis LOCATION: Lot 13
He pkia's Way
W. Barnstable, MA
SAMPLE DATE: 1-19-95
COLLECTED BY: L. Wile DATE RECEIVED: 1-19-95
TIME: 1:OOAM SAMPLE I.D. : , 13H
JOB TYPE: New well WELL DEPTH: 1401/91 ' Static
4" PVC Well
FLOW: 25 G.P.M.
RESULTS OF ANALYSIS:
Parameters Units Recommended Limit Result
Coliform bacteria/100ml (MF Method) 0 0
pH pH units 6.0-8.5 5.63
Conductance umhos/cm 500 146
Sodium mg/L 28.0 15.3
Nitrate-N mg/L 10.0 0.07
Iron mg/L 0.3 0.06
Manganese mg/L 0.05 0.007
Volatile Organics See enclosed report.
EPA 524 ug/L None detected.
COMMENTS: Low pH indicates high corrosive characteristics. ,
Yes No WATER IS SUITABLE FOR DRINKING POSES F PARAMETERS TESTED.
Date
Roriald J. S ri
Laboratory &rector
IT = Less Than
e
_,. GROUNDWATER
ANALYTICAL
EPA METHODS 601 and 602
Volatile Organics (GC/PID/ELCD)
Field ID: 13H Lab ID: 9772-01
Project: Davis/13 Helekia's Way Batch ID: VG2-0535-W
Client: Envirotech Sampled: 01-19-95
Cont/Prsv: 40mL VOA Vial/HCl Cool Received: 01-19-95
Matrix: Aqueous Analyzed: 01-20-95
PARAMETER CONCENTRATION REPORTING LIMIT
(ug/L) (ug/L)
Dichlorodifluoromethane BRL 5
Chloromethane BRL 5
Vinyl Chloride BRL 5
Bromomethane BRL 5
Chloroethane BRL 5
Trichlorofluoromethane BRL 1
1,1-Dichloroethene BRL 1
Methylene Chloride BRL 1
trans-1,2-Dichloroethene BRL 1
1,1-Dichloroethane BRL 1
cis-1,2-Dichloroethene * BRL 1
Chloroform BRL 1
1,1, 1-Trichloroethane BRL 1
Carbon Tetrachloride BRL 1
Benzene BRL 1
1,2-Dichloroethane BRL 1
Trichloroethene BRL 1
1,2-Dichloropropane BRL 1
Bromodichloromethane BRL 1
2-Chloroethyyl Vinyl Ether BRL 5
cis-1,3-Dichloropropene BRL I
Toluene BRL 1
trans-1,3-Dichloropropene BRL 1
1,1,2-Trichloroethane BRL 1
Tetrachloroethene BRL 1
Dibromochloromethane BRL 1
Chlorobenzene BRL 1
Ethylbenzene BRL I
meta-and para-Xylene * BRL 1
ortho-Xylene * BRL 1
Bromoform BRL 1
1,1,2,2-Tetrachloroethane BRL 1
1,3-Dichlorobenzene BRL 1
1,4-Dichlorobenzene BRL 1
1,2-Dichlorobenzene BRL 1
1QC SURROGATE COMPOUND SPIKED MEASURED RECOVERY QC LIMITS
a,a,a-Trifluorotoluene 30 31 102 % 87 - 113 %
1,2-Dichloroethane-d4 30 29 97 % 83 - 117 %
BRL = Bel_* Reporting Limit. * Hon-target compound. Method References: Method 601 - Purgeable
ir_4 14-tl-cc _.Z - '�urgeable Aromatics, 40 C.F.R. 125, k;;eTev k ti3uq.
Y 'd
--------------------- q _11_ '� �' �'T '' �" ,,�}- `
1- o-y 5 __:0= PNf 4'zRQ€ &?c} A L x 4 . .
r
TOWN OF'4$ARNSTABLE
LOOAn N SEWAGE
+' VILLAGE SSESSO 'S M P 6i LOT i
rNSTALLER'S NAME & PHONE NO.
.%-SEPTIC TAIJK CAPACITY
LLEACHING FACILITY:(type 6 o (size) b I� C ►11
° NQ"OF ZED PRIVATE WELL OR PUBLIC WATER-'A-xc
--------------
BUILDER OR OWNERS Q,ti
DATE PERMIT ISSUED:. 91 S�
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: .Yes No
13 S�
- a r
y7