HomeMy WebLinkAbout0040 JOSIAH'S PATH - Health 40 JOSIAH'S PATH,(BARNSTABLE)
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TOWN O ARNSTABLE
LOCATION "�A� OS��h�S Qd� SEWAGE #
VILLAGE �Ce�S R�J1vl ASSESSOR'S MAPIOL T-13;?�
INSTALLER'S NAME&PHONE NO. J�
SEPTIC TANK CAPACITY �//� D
LEACHING FACILITY: (type) IY G ) (size)
NO. OF BEDROOMS
BUILDER OR OWNER
PERMTTDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the 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 leaching facility).--- ��- n Feet
Furnished by (1,rcr"
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-`` COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAI AFFAIRS John Grad
DEPARTMENT OF ENVIRONMENTAL PROTECTION DEP Title V Septic Inspector
ONE WINTER STREET BOSTON MA 02108(617)292-3500 P.O.Box 2119
TeaTicket,Ma.
(508)564-6813
TRUDY COXE
Secretary
ARGEO PAUL CELLUCCI DAVID B.STRUHS
Govemor Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: 40 JOSIAH'S PATH BARNSTABLE
Name of Owner HALLAM
Address of Owner: SAME
Date of Inspection: 6/24/99 Qa vf9
9
Name oGRACl
/am a DEP approved system inspector pursuant to Section 15.340 of Tide 5(310 CMR 15.000) J U L 9 1999
� �0�►OF te7
Company Name: n/a I( Ogg
Mailing Address: n/a
Telephone Number: n/a
E ti
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 inspection.The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems.The system:
X Passes The inpection is based on criteria defined in Title V
Conditionally Passes code 310 CMR 15.303.My findings are of how the system is
Needs Further Eval ation By the Local Approving Authority performing at the time of the inspection.My inspection does
Fails not imply any warranty or guarantee of the longgevity of the
septic system and any of its components useful life.
Inspector's Signature: Date:6/26/99
The System Inspector shall ubmit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(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 Department of Environmental Protection.The original should be sent to the
system owner and copies sent to the buyer,if applicable,and the approving authority.
NOTES AND COMMENTS
THE SYSTEM PASSES TITLE V INSPECTION.THERE WAS 1'OF LEACHING LEFT AT THE TIME OF THE INSPECTION.RECOMMEND PUMPIN
SYSTEM NOW AND THEN MAINTAINING EVERY ONE TO TWO YEARS.RECOMMEND RAISING COVER TO THE LEACH PIT TO MAINTAIN IT
PROPERLY.
revised 9/2/98 Page 1 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 40 JOSIAH'S PATH BARNSTABLE
Owner: HALLAM
Date of Inspection:6/24/99
INSPECTION SUMMARY: Check A, B, C, or D:
A. SYSTEM PASSES:
I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist.Any failure criteria not evaluated
are indicated below.
COMMENTS:
System passes Title V inspection
B. SYSTEM CONDITIONALLY PASSES:
Wa 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.
Indicate yes,no,or not determined(Y,N,or ND). Describe basis of determination in all instances.If"not determined",explain why not.
Wa The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or
the septic tank,whether or not metal,is cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank
failure is imminent.The system will pass inspection if the existing septic tank is replaced with a complying septic tank as
approved by the Board of Health.
nta Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)
or due to a broken,settled or uneven distribution box.The system will pass inspection if(with approval of the Board of Health).
broken pipe(s)are replaced
obstruction is removed
distribution box is levelled or replaced
Wa The system required pumping more than four 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
revised 9/2/98 Page 2 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 40 JOSIAH'S PATH BARNSTABLE
Owner: HALLAM
Date of Inspection:6/24/99
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 the public health,safety
and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 16.303(1)(b)THAT THE SYSTEM IS
NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT ThE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of 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 AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well,
The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well,unless a well water analysis 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,Method used to determine distance nLa_(approximation not valid).
3) OTHER
nLa
revised 9/2/98 Page 3 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 40 JOSIAH'S PATH BARNSTABLE
Owner: HALLAM
Date of Inspection:6/24/99
D. SYSTEM FAILS:
You must indicate either"Yes"or"No"to each of the following:
I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303.The basis for this determination is
identified below.The Board of Health should be contacted to determine what will be necessary to correct the failure.
Yes No
X Backup of sewage into facility or system component due to an 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.
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 1/2 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 Wa.
X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation.
X Any portion of a 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 I 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.If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic ompounds,
ammonia nitrogen and nitrate nitrogen.
X The liquid level in the SAS is over the invert pipe,is in Hydraulic Failure.
E. LARGE SYSTEM FAILS:
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:
_ The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and
safety and the environment because one or more of the following conditions exist:
Yes No
X the system is within 400 feet of a surface drinking water supply
X the system is within 200 feet of a tributary to a surface drinking water supply
X 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)
The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.30412). Please consult the local regional office of the
Department for further information.
revised 9/2/98 Page 4 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 40 JOSIAH'S PATH BARNSTABLE
Owner: HALLAM
Date of Inspection:6/24/99
Check if the following have been done:You muse indicate either"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 None of the system components have been pumped for at least two weeks and-the system has been receiving normal flow rates
during that period.Large volumes of water have not been introduced into the system recently or as part of this inspection.
X As built plans have been obtained and examined.Note if they are not available with N/A,
X The facility or dwelling was inspected for signs of sewage back-up.
X The system does not receive non-sanitary or industrial waste flow.
X The site was inspected for signs of breakout,
X All system components,excluding the Soil Absorption System,have been located on the site.
X The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baffles
or tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum.The size and location of the Soil Absorption
System on the site has been determined based on:
X Existing information,For example,Plan at B4O,H,
X Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable)
[1 5.302(3)(b)]
X The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of
Subsurface Disposal Systems.
revised 9/2/98 Page 5 of 11
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 40 JOSIAH'S PATH BARNSTABLE
Owner: HALLAM
Date of Inspection:6/24/99
FLOW CONDITIONS
RESIDENTIAL:
Design flow:-Q g.p.d./bedroom
Number of bedrooms(design): 3 Number of bedrooms(actual):1
Total DESIGN flow: =
Number of current residents:-4
Garbage grinder(yes or no):NO
Laundry(separate system)(yes or no): NO If yes,separate inspection required
Laundry system inspected(yes or no):M
Seasonal use(yes or no):M
Water meter readings,if available(last two year's usage(gpd): nLa
Sump Pump(yes or no): MQ
Last date of occupancy: nLa
COMMERCIALIINDUSTRIAL
Type of establishment: n&
Design flow: nLa gpd(Based on 15.203)
Basis of design flow: nLa
Grease trap present:(yes or no):M
Industrial Waste Holding Tank present:(yes or no): �LQ
Non-sanitary waste discharged to the Title 5 system:(yes or no):11LQ
Water meter readings.if available:nLa
Last date of occupancy: n&
OTHER: (Describe)
nLa
Last date of occupancy: n&
GENERAL INFORMATION
PUMPING RECORDS and source of information:
nLa
System pumped as part of inspection:(yes or no):NQ
If yes,volume pumped nLa_ gallons
Reason for pumping: nLa
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)
I/A Technology etc.Attach copy of up to date operation and maintenance contract
Tight Tank Copy of DEP Approval
Other: nLa
APPROXIMATE AGE of all components,date installed(if known)and source of information:
THE SYSTEM IS 6 YEARS OLD.
Sewage odors detected when arriving at the site:(yes or no): NO
revised 9/2/98 Page 6 of 11
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 40 JOSIAH'S PATH BARNSTABLE
Owner: HALLAM
Date of Inspection:6/24/99
BUILDING SEWER:
(Locate on site plan)
Depth below grade: 1'
Material of construction:_ cast iron X 40 PVC _ other(explain)
Distance from private water supply well or suction line: TOWN
Diameter: nta
Comments: (condition of joints,venting,evidence of leakage,etc.)
nLa
SEPTIC TANK: X
(locate on site plan)
Depth below grade: E
Material of construction:X concrete_ metal_ Fiberglass _ Polyethylene _ other(explain)
nLa
If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): No
nLa
Dimensions: L 8'6"H 6'7"W 4'10"
Sludge depth: Z
Distance from top of sludge to bottom of outlet tee or baffle: 3
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:l"
Distance from bottom of scum to bottom of outlet tee or baffle: 17"
How dimensions were determined: MEASURED
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage,
etc.)
SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND RECOMMEND PUMPING NOW AND EVERY ONE TO TlA►O YEAR
GREASE TRAP:
(locate on site plan)
Depth below grade:
Material of construction:_concrete_ metal_ Fiberglass _ Polyethylene_other(explain)
nta
Dimensions: nLa
Scum thickness: n&
Distance from top of scum to top of outlet tee or baffle:jVa
Distance from bottom of scum to bottom of outlet tee or baffle n&
Date of last pumping: n&
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage,
etc.)
n&
revised 9/2/98 Page 7 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 40 JOSIAH'S PATH BARNSTABLE
Owner: HALLAM
Date of Inspection:6124/99
TIGHT OR HOLDING TANK: NO (Tank must be pumped prior to,or at time of,inspection)
(locate on site plan)
Depth below grade: n&
Material of construction:_ concrete_ metal_ Fiberglass _Polyethylene_ other(explain)
DLa
Dimensions: nLa
Capacity: n& gallons
Design flow: nta gallons/day
Alarm present: NQ
Alarm level:jita- Alarm in working order:Yes_No_ NQ
Date of previous pumping: Wa
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
nLa
DISTRIBUTION BOX: _
(locate on site plan)
Depth of liquid level above outlet invert:Wa
Comments:
(note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.)
nta
PUMP CHAMBER: NQ
(locate on site plan)
Pumps in working order:(Yes or No): NO
Alarms in working order(Yes or No): NO
Comments:
(note condition of pump chamber,condition of pumps and appurtenances.etc.)
Wa
revised 9/2/98 Page 8 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 40 JOSIAH'S PATH BARNSTABLE
Owner: HALLAM
Date of Inspection:6/24/99
SOIL ABSORPTION SYSTEM(SAS): X
(locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods)
If not located,explain:
nLa
Type:
leaching pits,number: 1000 GALLON LEACH PIT
leaching chambers,number: jiLa
leaching galleries,number: llla
leaching trenches,number,length: nLa
leaching fields,number,dimensions: nLa
overflow cesspool,number: nta
Alternative system: Wa
Name of Technology: -n&
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.)
THE LEACH PIT IS STRUCTURALL SOUND AND FUNTIONIN PROPERLY-THE PIT HAD 1'OF ACHING LEFT AT THE TIME OF THE
INSPECTION.
CESSPOOLS: _
(locate on site plan)
Number and configuration: Wa
Depth-top of liquid to inlet invert: Wa
Depth of solids layer: nLa
Depth of scum layer. nLa
Dimensions of cesspool: jI&
Materials of construction: n&
Indication of groundwater: n& inflow(cesspool must be pumped as part of inspection)nta
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
nLa
PRIVY: _
(locate on site plan)
Materials of construction:Wa Dimensions:nLa
Depth of solids: n&
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
nLa
revised 9/2/98 Page 9 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 40 JOSIAH'S PATH BARNSTABLE
Owner: HALLAM
Date of Inspection:6/24/99
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reference landmarks or benchmarks
locate all wells within 100'(Locate where public water supply comes into house)
n/a
Cl
�q l�
I�(391
revised 9/2/98 Page 10 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 40 JOSIAH'S PATH BARNSTABLE
Owner: HALLAM
Date of Inspection:6/24/99
NRCS Report name: nla
Soil Type: n[a
Typical depth to groundwater: Wa
USGS Date website visited: n&
Observation Wells checked: NQ
Groundwater depth:Shallow _ Moderate _ Deep _
SITE EXAM _ Slope
_ Surface water
_ Check Cellar
_ Shallow wells
Estimated Depth to Groundwater 12 Feet
Please indicate all the methods used to determine High Groundwater Elevation:
_ Obtained from Design Plans on record
X Observed Site(Abutting property,observation hole,basement sump etc.)
_ Determined from local conditions
_ Checked with local Board of health
_ Checked FEMA Maps
_ Checked pumping records
_ Checked local excavators,installers
X Used USGS Data
Describe how you established the High Groundwater Elevation.(Must be completed)
USGS MAPS AND CHARTS AND VISUAL-12+FEET
revised 9/2/98 Page 11 of 11
TOWN OF BARNSTABLE '
LOCATION Z07v fa �p S ; Gih r A// SEWAGE # W-353
VILLAGE tAll (�<r6�Sf�i��e ASSESSOR'S MAP & LOT "'I " ®93
INSTALLER'S NAME & PHONE NO. oAh hN bo c/,2f 05-Sr
SEPTIC TANK CAPACITY /0002
v
LEACHING FACILPTY:(type) i_f (size)
NO. OF BEDROOMS PRIVATE WEL OR PUBLIC WATER
BUILDER OR OWNER Azli 1�el--
DATE PERMIT ISSUED;
DATE COMPLIANCE ISSUED: �J�� • f�-
VARIANCE GRANTED: Yes No �/
l Q
6-7
l
l � 7
l �
FEs.....`Q.4f).........
THE COMMONWEALTH OF MASSACHUSETTS
P -7 77 BOARD OF HEALTH
...........'_17�_4....O F...... . ...... ..V` 1
Appliration for Mipasal Works Tonotriutiun Permit
Application is hereby made for a Permit to Construct `/� or Repair ( ) an Individual Sewage Disposal
System at: / ^.�. ��Z�. ..
......---•-_....--........ /1�.....o. �� •-•---. .._.._._.. .............•--..........................
Location•A ress or Lot No.
............... _..... .l.G . ..... - •-•--••---........................... .........----........................._.....
er Address
►W.a 7......_...1 Am......................................... ............................................
Installer Address
Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms......... .... Expansion Attic ( ) Garbage Grinder ( ).04 a Other—Type T e of Building No. of persons....................-..-.-. Showers — Cafeteria
04 Other fixtures .---•......-•---•-•--••..............
Q .................. ... . •......... .•...._......_.__.................................
Design Flow..............1. .........._...gallons per er(da . Total dal f ow_............. .al
W >m �. .. .. 1'a P P �r 1 Y �.�.�............. lons�.
WSeptic Tank—Liquid capacit i!ZJ gallons Length.- -.. Width;..fAld.. Diameter................ Depth��---�..q,..
x Disposal Trench—No..................... Width.................... Total Length..................... Total leaching area....~......... ft.
3 Seepage Pit No......../........... Diameter.....J. ..... Depth below inlet.... .,. Total leaching area....(... sq. ft.
L. ..
Z Other Distribution box Dosing tank ( )
Percolation Test Results Performed by...._.... c1!l,f.....—. z ......... Date........
Test Pit No. 1...L2..minutes per inch Depth of Test Pit......L!tl .Tft Depth to ground water.... r��,A.
GL, Test Pit No. 2....�?minutes per inch Depth of Test Pit..... . 4..- Depth to ground water...................
a •-- • .. .. ............................................................................................................................
O Description of Soil.... .� ..._ ...........
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 LITLZ 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has ben issued by the board of health.
Signed..�...... . ................ ._._.. ..............
Date
Application Approved By........... .4 d``* --------------•-•----•-•------------•---•--- ••---.....
Date
Application Disapproved for the following reasons:............................................................................................................
.............................••----------•-......................--------......---...........-•------••-••-•••--•----•------•--•-------•--••----•--•.........._..........---•............---••-•-•----
DatePermit No.....- 3•e`�P --------------------- Issued........................................................
Date
�`.-
No..9 2-. �.. yf 1< y J FI;:a.....1 �'�........._
THE COMMONWEALTH OF MASSACHUSETTS'V
-7 7a 7 BOARD OF HEALTH ' :a
............_rat)4.....OF.......849JQ57_P64&. ..............
Applirtttinn for Disposal Works Tonstri
qgio.n �P�mit
Application is hereby made for a Permit to Construct O or Repair ( ) an 'Individual Sewage Disposal
System at: �/76
................—_....___��. �_�� -''.......__................................. Location-Address ......................................
W (�// / n� ....................Address
a •....... -•�,a...... •.Zj... .... ..............................
Installer Address
Type of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms............. .__...._...._...._.._..Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Buildingtl`................:�....- No. of persons............................ Showers ( ) — Cafeteria ( )
QOther fixtures ...................................... ............•--•--••-------.....----•-------....---•-••••--•••--•--•....---•...........................
W Design Flow.............. �._en................gallons per person pe I•day. Total da}ly flow.......... ..............gallons,,
WSeptic Tank—Liquid capaciiy!Q. Wgallons Length...&.�-1_. Width:.._ 1_.1- -_ Diameter................ Depth�.I.."...
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area..................sq. ft.
3 Seepage Pit No........ .......... Diameter.....!Zr..... Depth below inlet..-...:.. .. Total leaching area....�y.�..sq. ft.
z Other Distribution box ( Dosing tank ( )
~" Percolation Test Results�^•� Performed by........... jn.,._...C... c................... Date....... C..`...%........
Z
Test Pit No. I...4n2...minutes per inch , Depth of Test Pit......L.��t f�(Depth to ground water.........
.. ...l. .
44 Test Pit No. 2....c_..2...minutes per inch Depth of Test Pit.....n.q V.... Depth to ground water.. �GU�
fYie ,•-- ------------ ............................-•----•--.........................................................
O Description of Soil..... ' : �./1-6 `
.» '-
•---•-•................. ------------------------•---------------------------------------- •-------••--•••--
---...•-------•••-----—r—�---/
W -----------------•---...........--•---•----•--•--••--------•--------......•........I..,f
......................................
•----•..................................----......--•-----..........-•--•-•----..........-•------•---............-----------..:._........._..-•----.....-••--•--.............................._.........
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 LITLW 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has�beeen issued by the board offhealth.
/7
Signed..!� 1 ......./l �IiT�1'.. .......... ..._....
--- ... ........ Date
Application Approved B r. ..........
Date
Application Disapproved for the following reasons:............................................................................................................
---
..........................................................................................................--•-•--•....._....---•---••-•-•••--•---•---•........---•--•••----•--............••------_---•.
Permit No..... - .`� ..................... Issued.............................. Date........
Date
>m a- .r...,...nra..o.-.wc,.ver.-•-.err••,!.T w....?e.1lR... .....9.........................
/�w..w.�..IL•w.S•RR'T�Ivv AO�v1.N.NW.rs Y+a.ve�iSl.s.tls�o�ro-..�mw.a
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
............ r L..............OF......... ' r: .!. 0r ..........................................
�rrtif utt#r of faum�littnrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (k) or Repaired ( )
bY......................... �............. .; ''
Installer
at1 / 5"n .' --• ' ----------------------------------------------
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No..... .......... dated................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.t .................................... Inspector....................................................................................
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THE COMMONWEALTH OF MASSACHUSETTS
,� BOARD OF HEALTH
.........129r2.':..4...............OF........... -..Mr'e>�A ............................................
FEE.../A.............
Disposal Works Tunstrurtion rrrmit
Permission is hereby granted........... s r. w APAft.......................................................................................
to Construct (V) or Repair ( ) an Individual Sewage Disposal System
atNo................... +-r�..ni: ...I. = -......_... /1.= ( _ -............_...........---•----..................
Street
as shown on the appl'catio- for Disposal Works Construction PiniIgo . Daled !?�._.o.................... ...
�A,, (/�/
................:............. -•ei't•<-•-
----------_........................ ¢ �•.
lloanl of Health
DATE..............7 r1
s _
-LI
ENVIROTECH LABORATORIES
Mass. Cert. #:MA063
449 Route 130 Sandwich, MA 02563 • (508) 888-6460
CLIENT: Larry Nickulus LOCATION: Lot 12 Josiah's Path
ADDRESS: W. Barnstable, MA
COLLECTED BY. L. Wile SAMPLE DATE: 6-29-92 TIME:
DATE RECEIVED:�2n_9 SAMPLE ID: 33
JOB #: New Well WELL DEPTH:
RESULTS OF ANALYSIS:
Parameter Units Recommended limit Result
Coliform bacteria/100 ml (MF Method) 0 0
pH pH units 6.0-8.5 6.80
Conductance umhos/cm 500 128
Sodium mg/L 20.0 14.9
Nitrate-N mg/L 10.0 <0.03
Iron mg/L 0.3 0.74
Manganese mg/L 0.05 0.12
Hardness mg/L as CaCO3 500 23.8
Sulfate mg/L 250 1.1
Potassium mg/L 20.0 0.8
Alkalinity mg/L 200 5.6
Chloride mg/L 250 15.8
Turbidity NTU 5.0
31
Color APC units 15.0 8.0
Background bacteria
COMMENT: Iron and manganese are not health hazards, but can cause taste, staining &
EPA Method 601/602^ ug/L Below reporting limit odor proble s.
* See attached report
M NO WATER IS SUITABLE FOR DRINKING PURPOSES FOR PARAMETERS TESTED.
DATE-2 S q1L
r
s
11L
t
GROUNDWATER
ANALYTICAL EPA METHODS 601 and 602
Volatile Organics (GC/PID/ELCD)
Field ID: Z-633 Lab ID: 3387-01
Project: Nickulas Batch ID: VHA-1017-W
Client: Envirotech Laboratories Sampled: 06=29-92
Cont/Prsv: 40ml VOA Vial/HCl Cool Received: 07-02-92
Matrix: Aqueous Analyzed: 07-08-92
PARAMETER CONCENTRATION REPORTING LIMIT
(ug/L) (ug/L)
Dichlorodifluoromethane BRL 5
Chloromethane BRL 1
Vinyl Chloride BRL 1
Bromomethane BRL 5
Chloroethane BRL 1
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-Chloroethylvinyl Ether BRL 1 4 '
trans-1,3-Dichloropropene BRL 1
Toluene BRL 1
cis-1,3-Dichloropropene BRL 1
1,1,2-Trichloroethane BRL 1
Tetrachloroethene BRL 1
Dibromochloromethane BRL 1
Chlorobenzene BRL 1
Ethylbenzene BRL 1
m+P-Xylene * BRL 1
o-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
QC SURROGATE COMPOUND SPIKED MEASURED RECOVERY QC LIMITS
Bromochloromethane 30 30 99 % 83 - 117 %
Fluorobenzene 30 30 102 % 87 - 113 %
BRL = Below Reporting Limit. * Non-target compound. "Trace" indicates probable presence below listed
Reporting Limit. Method References: Method 601 - Purgeable Halocarbons and Method 602 - Purgeable
Aromatics, 40 C.F.R. 136, Appendix A (1986).
No. --- '� Fee- ---------------
BOARD OF HEALTH
TOWN OF BARNSTABLE
ApplicationArVell
Co �tructionpermit
pplication is hereby made for a permit to nstruct ( ), or Repair ( )an individual Well at:
kcf _1_-Zr---- 5,1!lr - --- A --------------------------------------
ocation — Address Assessors Map and Parcel
------------------------------------------ dofi-�� � .� ��-h
Owner Addres�
Installer — riper Address
Type of Building
Dwelling ---- -- ---------------------------------
Other - Type of Building-------------- -------------------- No. of Persons---------------------------------------------------------
`( ------
P� Capacity -Type of Well--C�--,,------ ---------- -=- - P Y---------------------
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 - - - -- - - - ------�-Kt -
date f
-- ---------------- ------------- --- f
Application Approved By----- - --- - ---- - - �`-�---G-��--
date
Application Disapproved for the following reasons:- ------------ ------------------------------------------------------------
-------——------—-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------
date
Permit No.- -~ ��`�-� Issued -—--
-- - — --- -c- - ----------
date
BOARD OF HEALTH
TOWN OF BARNSTABLE
(fertificate ®f (Compliance
THIS IS OCC TIFY, hat the Individual Well Constructed (�ltered ( ), or Repaired ( )
byp __� - - ------------------------------------------------------------------------------------------------------------------------------------
—— Installer
at. t- -, a /,� — - -- — -- '----- -- -- ---- -
has been installed in accordance with th'e provisions of the Town of Barnstable Board of Health Private Well Protection
Regulation as described in the application for Well Construction Per". -1 y - -- ated---------`= = ��
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL
SYSTEM WILL FUNCTION SATISFACTORY.
DATE--------------------—------------------------------------------------------ Inspector--------------------------------------------------------— - -
No.-----------�----�- � Fee-
BOARD OF HEALTH {
TOWN OF BARNSTABLE
ZippYication-ftVrIl Con!5truct ion 3pdmit
Application is hereby made for a permit to Construct (�, Alter ( ), or Repair ( )an individual Well at:
°` —-- f= — S ` { -- --------------------—-----—--------------------------------------- —------ -------------------- •Q - -�°----------------
---- - - — -- Parcel /
�— ocatio� Address � Assessors Ma and M1 ---- � ��-_-
Owner , Addres4'
/ Installer — Driller Address
Type of Building
Dwelling------------------------------------------------------------
Other - Type of Building ------------ - No. of Persons---------------------------------------------------------
Type of Well- - V — ; -------------------- 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.
l/►.t =- �°-- ------ -----------------------------
Signed — date
Application Approved By— -----------_-- - - �- ol
'�`O -
date
Application Disapproved for the following reasons:-
-----------------------------------------------------------------------------
-----------------
` date
Permit No.— I'' / --——-- -- —— Issued — — ---— -- --�—-r-- — ew,r-------- ' date f
.d
BOARD OF HEALTH
TOWN OF BARNSTABLE
Certificate ®f Compliance
THIS t IS TO,.CERTIFY, That the Individual Well Constructed (L,) Altered ( ), or Repaired ( )
by--�--=-A-e^— - +-_ -----------------------------------------------------------------------------------------------------------------------------------------------
t Installer
at�&�--ry---------- �---------- -f/V-h _ ..
has been installed in accordance with th'e provisions of the Town of Barnstable Board of Health Private Well Protection
Regulation as described in the application for Well Construction Per/4V- --��� D ed-
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL
SYSTEM WILL FUNCTION SATISFACTORY.
DATE-------------------------------------------------------------------------------------- Inspector------------------------------------------------------------------------------------
BOARD OF HEALTH
TOWN OF BARNSTABLE
Very Con5tructionVermit
No. -�
..�,��,.�`_.�,r- Fee�`=—�-----------
I, ,(�
Permission is hereby granted�`i----1,�-���---"`"'------- "--------
------------------------------------------------------------------------------
to Construct *1, Alter ( ), or Repair ( ) an Individual ell at:
No. 4d 1--f�------------------J-r--e>14-V------ --------r --- l'-'K--------------------------------------------------------------------------------------
Street
as shown on the application for a Well, Construction Permit
No. 9 - 1------ -------------------------- Dated---------- "ar iq' onna-------------------------------
----------
r�- Board of Health
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