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HomeMy WebLinkAbout0016 KETTLEHOLE ROAD - Health 16 KETTLE HOLE RD., W. BARNSTABLE A=109-019 Fj o r' d / TOWN OF BARNSTABLE LOCATION f_[s. �0� � 4/,� �� SEWAGE # VILLAGE A-1 ° B41- ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. 171) 7 SEPTIC TANK CAPAC=2Y ,—/ &6�' LEACHING FACILITY: (type).)�� e (size) NO.OF BEDROOMS BUILDER OR OWNER PERMTTDATE: a_�J .��1 COMPLIANCE DATE;3-./2-9 7 'Separation Distance Between the: Maximum Adjusted Groundwater Table to the /etlands'exist Facility Feet Private Water Supply Well and Leaching Facxist on site or within 200 feet of leaching facili Feet Edge of Wetland and Leaching Facility(If an within 300 feet of leaching facility) Feet Furnished by f� fL No. . � Fee BOARD OF HEALTH TOWN OF BARNSTABLE 2pplicatiou _for Yell Cougtructiou Perron Application is hereby made for a permit to Construct( Alter( ), or Repair( ) an individual well at: Location-Address Assessors Map and Parcel V t s" 1(,¢ `fit C� d� (�E� , �Cil''115-174,b k, ��>f}C2&&R Owner Address mood �p�tl 0rii�1 � Ih�� 0, � 27$� ��f�ann , NA o��S�i Installer-Driller Address Type of Building Dwelling V Other-Type of Building No. of Persons Type of Well_ G & U Capacity Purpose of Well £�P�. Agreement: The undersigned agrees to install the afore described 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 Certi ate of Compliance has been issued by the Board of Health. Signed I n Zl Date Application Approved Date Application Disapproved for the following reasons: Date Permit No. W � �O — I Issued -3A) Date BOARD OF HEALTH TOWN OF BARNSTABLE (Certificate of (tompliauce THIS IS TO CERTIFY,that the individual well Constructed 06, Altered( ), or Repaired( ) by '4Q&fY1Dy)A Wed l b C , Installer at tU has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private WAxmo ' Regulation as described in the application for Well Construction Permit No:��-dfj Dated ` THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORILY. Date Inspector No. 1 rb� Fee BOARD OF HEALTH TOWN OF BARNSTABLE ZippYicatiou _for Yell Cougtruction' Vermit Application is hereby made for a permit to Construct ; Alter( ), or Repair(') an individual well at: Location-Address 'Assessors Map and Parcel .phl"11i)- \/lsall Owner ' Address ` t`.k�ma�d 11\)ell ordilr ll lnr- P0, 130X 279--1) or(o0n,�, MA dzcp5a Installer-Driller J d Address + Type of Building Dwelling Other-Type of Building No. of Persons i Purpose of Well S1'1G Agreement: The undersigned agrees to install the afore described 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 Certi cate of Compliance has been issued by the Board of Health. j Signed . ..A.t .�, t �.(� 2 Zl Date ' Application Approved By: _ -- Date " Application Disapproved for the.following reasons: -,....k• _ _. Date _ _ Permit No. Issued A) 3 AI _ r Date BOARD OF HEALTH TOWN OF BARNSTABLE (Certificate of Compliance THIS IS TO CERTIFY,that the individual well Constructed( Altered( ), or Repaired( ) by I Q�5.nnohA yye l I r 1 rin J Installer p at 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.k'j Dated t v THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORILY. Date Inspector BOARD OF HEALTH TOWN OF BARNSTABLE Well Cougtructiou Permit y. No. Oclq Fee c Permission is hereby granted,to -, �( Installer. _ +' ' to Construct,((), Alter( ), or 'Repair( ') an individual well at: 4, !+ No. 1( 4-2. *, Street ,. as shown on the application for a Well Construction Permit No.� �"' ��--�_ Dated � jG3 Date - / y�� Approved Bye` Massachusetts Department of Environmental Protection Bureau of Resource Protection Well Completion Reports Well Driller Please specify work performed: Address at well location: New Well Street Number: Street Name: 16 KETTLEHOLE RD Please specify well type: Building Lot#: Assessor's Map#: Domestic 109 Assessor's Lot#: ZIP Code: Number Of Wells: 19 02668 City/Town: Well Location BARNSTABLE In public right-of-way: GPS C Yes No North: West: 41.70948 70.39526 Subdivision/Property/Description: Mailing Address: rclick here if same as well location addres Property Owner: Street Number: Street Name: PHILIP VISALI 16 KETTLEHOLE RD City/Town: State: Engineering Finn: BARNSTABLE MASSACHUSETTS ZIP Code: 02668 Board of health permit obtained: t Yes (7 Not Required Permit Number: Date Issued: W2021009 02/17/2021 ��s' I Massachusetts Department of Environmental Protection r^•. Bureau of Resource Protection—Well Driller Program dz ,> Well Completion Reports(General) Well Driller - General Well Form DRILLING METHOD Overburden Bedrock uger Choose Bedrock— WELL LOG OVERBUR DEN LITHOLOGY _ [Fromi(ft) To(ft)— Code Color Comment _ Drop in drill Extra fast or slow Loss or addition stem drill rate of fluid �'' f'?Fast r Slow 0 20 Fine To Coarse S{� Brown �.— �Y7E �� Loss Addition 20 40 Fine To Coarse S!�< Brown T ES r Fast( Slow oss A dition _ ........ _.. ..... ..... ._ ...... .. _. ....... ._._.. .... ... ... .. ... ....................._-....................... . .......... .. 40 _ 50 Fine To Coarse S i Brown r Fast r Slow k; YES NO Loss Addition �;�� =YESNO 50 70 Fine Sand Brown r r Fast r Slow Loss Addition 70 l85 _---_- I Fine Sand..•.._.....•..' :i Brown [r+' r Fast f`Siow YES NO _. Loss Addition 85 98 SSilty Sand Brown r 0 C Fast C`Slow YES NO _� [Loss Addition � � �� 98 100 Medium Sand er Brown • r r r Fast C Slow YES NO ___ loss Addition ................._.._...........-...........—...... -........- -- ---._..._.................................._...,..........----.....--.......--._............___............................._......._....._...--._.. ......._.....................................................................................__......................._................._.........-......... 100 107 Silty Sand Brown Cf r Fast C Slow C", r L--= YES NO Loss Addition n � �' [ I =YESNO rFine To Coarse S i;� Li ht Gray (!� r�Fast� Siow Loss Addition WELL LOG BEDROCK LITHOLOGY Drop In Extra fast or Loss or Visible Rust Extra From(ft) TOM) Code Comment addition of Large drill stem slow drill rate fluid Staining Chip s ..-- ---... Yes rYes']1[;;] Fast Slow Loss Addition -• ADDITIONAL WELL INFORMATION Developed t:Yes r No Disinfected C:Yes r No Total Well Depth 115 Depth to Bedrock Surface Seal Type None racture Enhancement Yes No CASING r is Casing above ground? From: 1 Ta 0 From To Type Thickness Diameter Driveshoe — - --- — — --- - — . ... .. -- _.. � 111 Polyvinyl Chloride ��` Schedule 40 r Yes SCREEN No Screen Massachusetts Department of Environmental Protection Bureau of Resource Protection—Well Driller Program Well Completion Reports(General) From To Type Slot Size Diameter 111 115 Stainless Steel Well Point 0.015 0 WATER43EAPJNG ZONES (-DRY WELL-I From To Yield(gpm) 48 115 12 PERMANENT PUMP(IF AVAILABLE) Wire Constant Speed Pump Description Horsepower Submersible L Pump Intake Depth(ft) 80 Nominal Pump Capacity(gpm) 10 ANNULAR SEAL/FILTER PACK From To Material 1 Weight Material 2 Weight Water Batches Method Of (gal) (count) Placement F-- r oose Material Choose Material Choose Ce One- :T L_ -- ------ — ---.. _o s WELL TEST DATA Date Method Yield(gpm) Time Pumped Pumping Level(ft Time To Recover Recovery(ft (HH:MM) BGS) (HH:MM) BGS) 02/24/2021 Constant Rate Pump 12 01:30 53 00:01 j48 WATER LEVEL Date Static Depth BGS(ft) Flowing Rate(gpm) Measured ..r 02/24/2021 48 12 COMMENTS WELL DRILLERS STATEMENT This well was drilled or altered unde"my direct supervision,according to the applicable rules and regulations,and this report is complete and accurate to the best of my know edge. Supervising Driller DESMOND THOMAS E Monitoring[M] Signature III, DrillerDESMOND III Registration# 764 THOMAS,E ' E.NVIROTECH LABORA TORIES,INC. MA CERT. NO.:M-MA 063 8 Jan Sebastian Drive Unit 12 Sandwich,MA 02563 (508)888-6460 1-800-339-6460 FAX(508)888-6446 Client Name: Desmond Well Drilling Location : Address: PO Box 2783 16 Kettlehole Road Orleans, MA W.Barnstable, MA 02653 Lab Number: DW-210621 Collected By: Desmond Well Drilling,Inc. Date Received: 02/25/21 Sample Type: Raw Well Specs: New Well 115748' Loctitlon Source` ,Date Collected '""`'Ttie Collected 7�` A, _ :a. 021216121 .30 Analysts Requested Units Recommended Limits Analysis Result Method Date Analyzed[Analyzed By; ......... Total Collform CFU/100mL 0.. . 0 SM9222B 02/25/2021 JR @ 13:00 pH pH units 6.5-t3.5 6.25.... SM 4500-H-B . 02/25/2021 . . SD mg1L 1.00 �0.006 EPA 3 .0 Specific Conductancen umhos/cm 500 184 EPA 120.1 02/25/2021 SD ,,. _... _, _ ........ ...._ _ . .. ._._._ .... Nitrite-tV O2125/2021 SD Nitrate-N mg/L 1`0.0' 0.03 EPA 300.0 02/25/202t SD - Sodium mg/L 20.0 18 EPA 260.7 03/02/2021 KB .... _... .. ,m. Total Iron mg/L 0.3 1.62 EPA 200.7 03102/2021 KB Manganese mglL. 0.05 0.098 EPA 200.7 03/02/2021 KB Volatile Organic Compounds' ug/L See comment. See attached EPA 524.2 02/26/2021 NEC Comments: pH is below recommended limit and may have corrosive characteristics. Iron Level is not a health hazard,but may cause taste and staining problems. Drinking water may naturally have manganese and,when concentrations are greater than 0.050 mg/L,the water may be discolored and taste bad.Manganese is not a health hazard at levels 0.05-0.300 mg/L. *2-Butanone and acetone are found in the PVC glue used for well construction. *Limits:2 Butanone 4000 ug/L,Acetone 6300 ug1L *Trace to low levels of chloroform are occasionally detected in ground water in coastline areas. *MTBE limit is 70 ug/L. All samples were analyzed within the established guidelines of US EPA approved methods with all requirements met, unless otherwise noted at the end of a given sample's analytical results. We certify that the following results are true and accurate to the best of our knowledge. Water meets EPA standards and is suitable for drinking for parameters tested. Dale 3/3/2021 Ronald J.Saari Laboratory Director BRL=Below Reportable Limits *See Attached Page 1 of 1 c- ertification is not available for this analyte for potable water samples.. I _ 'rr New England Chromachem + 6 Nichols Street Salem, MA 01970 978-744-6600 „Sample Information EPA Method 524.2 Rev 4.1 Volatile Or anic Compounds.In Water Lab ID:..._ 102411 Client., Envirotech Laboratoryi Inc. Client ID: DW-210621 State: Liquid Date Sampled: 02/25/21 Date Received:. ... 102J26/211. Date Analyzed: 02/.26/21 NICL Re ulated.VOC's Results(uglL) (ug1Lp Unregulated VOC's __Results ug/L) Benzene ND 5 Acetone 18.5 Carbon Tetrachloride 7777, Bromobenzene IND 91-Dichloroethene ND 7 Bromochlorornethane ND 1',2-Dichloroethane ND 5 Bromodichloromethane ND 1,2-Dichlorobenzene ND 600 Bromoform ND 1,4-Dichlorobenzene ND 5 Bromomethane ND Trichloroethene ND 5 2-Butanon...e $1.8 1,1,1 Trichioroethane ND 200 N-Butylbenzene 'ND Vin Chloride ND 2 Sec-But benzene ND Chlorobenzene ND 100 Tart-B utyl benzene ND cis-1,2-dichloroethene ND 7.0 V Chioroethene N.D trans-1,2-dichl6roethene ND 100 Chloroform 1.11 1,,21.... 1,2-Dichioro ropane :", NQ_ 5 Chloromethane ND Eth`ibenzene ND 700 2-Chiorotoluene ND Styrene ND 100 4-Chlorotoluene- ND Tetrachioroethene ND 5 ' DIV mochioromethane 'ND Toluene " ND 1000 1,2-Dibromo-3-Chlaropropane ND X enes Total "' ND 10000 1,2-Dibromoethane IND 'Methylene Chloride ND 5 Dibromomethane ND 1,2,4-Tdchlorobenzene ND 70 1,3-Dichlorobenzene ........ ND _...... 1,1,2-Trichloroethane ND 5 17.ichlorodifluoromethane ND ` 1,1-Dichloroethane ND _ Acetone Detection Limit=10 ug/L 1,3-Dichloropropane ND ND=<Method Detection Limit 2,2-Dichloropropane ND NA=Not Analyzed M-Dichloropropene ND cisA,3-Dichloropropene ND trans-1,3-Dichloro ro ene ND Hexachlorobutadiene ND isopropylbenzene ND _,- P-Isalino ``toluene. ND Meth -tent-but I ether 1.81 Naphthalene ND N-Prop"''benzene ND 1,11,2-Tetrachl6roethane ND . 11,2,2-Tetrathloroethane ND .. .. 1,2,3-Trichlorobenzene ND Trichlorofluoromethane ND 1,2,3-Trichloro ro ane IND 1,24-Trimeth (benzene. NO 1 3 5-Trimeth (benzene ]ND Surrogate Standard Recoveries. Benzene-d6 .... 100 MCL TTHM's=80 ug/L 4-Bromofluorobenzene 96 Method Detection Limit=0.5 ug/L 1,2-Dichlorobenzene-d4 93 Analysis performed per 31OCMR42 Electronically signed and approved by Mr.Bruce A.Bornstein,Lab Director Date: 3/1/2021 N t No. / Fee$5 0 THE COMMONWEALTH OF MASSACHUSETTS Entered in compute Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE,, MASSACHUSETTS 01pphration for Mt.5pogar *p.5tem Con%tructton 3dermit Application for a Permit to Construct( )Repair(x )Upgrade( )Abandon( ) El Complete System O Individual Components Location Address or Lot No. 16 Kettle Hole Rd.. , Owner's Name,Address and Tel.No.M i C h a e 1 Pr inc i W. Barnstable , MA same Assessor's Map/Pazcel /d _ 0/ Iyalle�Name,Andress,and Tel.No. Designer's Name,Address and Tel.No. Wm tfooinson Septic Service P.O . Box 1089, Centerville , MA Type of Building: Dwelling No.of Bedrooms �5 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Gravel Nature of Repairs or Alterations(Answer when applicable) Install an additional 1 , 000 gal. tank. D-box and. `i leach chambers . Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental ,,,de and not to place the system in operation until a Certifi- cate of Compliance has been issued by this B d Health. ^� Signed Date �t Application Approved by Date. Application Disapproved for the following reasons Permit No. ~ Date Issued ca No. Fee 1 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS ZippYication.for Zigpool *potent Construction Vermtt Application for a Permit to Construct( )Repair(X )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 16 Kettle Hole R d. 0ggei�@Name,Address and Tel.NoM ichae 1 Pr inc i W. Barnstable MA Assessor's Map/Parcel install e ' Name, d ss,and Tel o. Designer's Name,Address and Tel.No. wm ' nson Aptic Service P.O. Box 1089, Centerville, MA Type of Building: Dwelling No.of Bedrooms 4/5 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Gravel Nature of Repairs or Alterations(Answer when applicable) Install an additional 10000 gal. tank, D--box and 3 leach -chambers. r�`?"�11/✓ Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this B azd Health. 7 n Signed J i Date 7 Application Approved by F Date E; Application Disapproved for the following reasons r Permit No. Date Issued ' THE COMMONWEALTH OF MASSACHUSETTS Pr inc i BARNSTABLE, MASSACHUSETTS Certificate of (Compliance THIS IS TO fERTIFY,tat the On-site S�ewae Disp sal S stern Constructed( )Repaired ('� )Upgraded( ) Aband(y�e m. ts. obinson @p lc erVylee 1 O C1.6 t�h- 'e i • , YY• Barnstable, !vl at has been constructed irLaccordapce,� with the provisions of Title 5 and the for Disposal System Construction Permit No.7 "f! dated / f Installer Wm. E. Robinson Septic S er. Designer A Al The issuance of thi peYh onstrued as a guarantee that the s�!1 �nill� ?/ti° as d�'gned. Date Inspector ��(/� �� No. ,? ------------------------=—Fee $50 -- �I f THE COMMONWEALTH OF MASSACHUSETTS Pr inc i PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Mioaar *pgten ComAruction Vermtt Permission is hereby SrarnicdLtQ i isIV ,V16Wt ( a�� nd� ) System located at and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. . Provided:Construction must be completed within three years of the date of trmit. j- Date: � �'' � � ,� Approved b� 0 NOTICE: This Form Is T o Be Used For The Repair Of F aileu Septic Systems Only. 0 CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT ENGINEERED PLANS) I, William E, Robinson, Sr. ,hereby certify that the application for disposal works construction permit signed by me dated mil" concerning the property located at 16 Kettle Hole Rd W,Barnstable MA meets all of the following criteria: Th re are no wetlands within 100 feet of the proposed leaching facility. �J There are no private wells p ate we s within 150 feet of the proposed septic system. 4/There is no increase in now and/or change in use proposed. �U I'There are no variances requested or needed. 1 If the proposed leaching facility will be located with 250 feet of any wetlands,the bottom of the proposed leaching facility will not be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation. Please complete the following: A)Top of Ground Elevation(according to the Engineering Division G.I.S. map) 9'0t, B)Observed Groundwater Table Evaluation(according to Health Division well map) J, SIGNED: 1 r DATE LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER 60 (Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan, this plan should be submitted). d OSbG� V" TOWN OF BARNSTABLE LOCATION /�,c/I�`� r�f�l �1 SEWAGE # —f � VILLAG ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. i �, 7 / SEPTIC TANK CAPACITY-),-IC&(t�� LEACHING FACILITY: (type) c: (size) NO. OF BEDROOMS BUILDER OR OWNER /t A.C_ j. PERMIT DATE: —//�— ` �l COMPLIANCE DATE;5.I i Separation Distance Between the: Maximum Adjusted Groundwater Table to the /etlands Facility Feet Private Water Supply Well and Leaching Facxist on site or within 200 feet of leaching facili Feet Edge of Wetland and Leaching Facility(If an within 300 feet of leaching facility) Feet Furnished by I C' a 1 � P i. COINTMOINWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS -� DEPARTMENT OF ENVIRONMENTAL PROTECTION C\` ONE VVINTER STREET, BOSTON MA 0210E (61 i) 292-5600 TRUDY CORE Secretan• ARGEO PAUL CELLUCCI Michael Pr inc i DAVID B. STRt HS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 16 Kettle Hole R oad. Name of Owner Michael Pr ine i IN.- Bar stable , MA Address of Owner: g g Me Date of Inspection:S/'/— Name of Inspector:(Please Print) tm. E . Robinson S r . I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) CompanyName:{Am. E . Robinson Septic Service Mailing Address: P.O . Box 1089, Centerville , MP Telephone Number: �2!�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: t/Passes Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signature: 4j+ ' Date: The System Inspector shall submit 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 Raw 9 10 (MAY 2 1999 F BARNSTABLE LTH DEPT. revised 9/2/98 Page Iof11 N i. Printed on Recycled Paper 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM 4 PART A CERTIFICATION fcordinued) "rop"Address: 16 Kettle Hole Road., W. Barnstable , MA awner: M i c a e l Pr in c i Date of Inspection: INSPECTION SUMMARY: Check eB, C, o/ D: A. SYSTEM PASSES: AI 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: K/ c7V•f r /J,�a{v 7 ��� 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. Indicate y s, no, or not determined(Y, N, or ND). Describe basis of determination in all instances. If "not determined", explain why not. 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. 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 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 2of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION fcontinued) Property Address: 16 Kettle Hole Road., W. Barnstable , MA Owner: Michael Princi Date of Inspection: 3-1 7_9 0 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 15.303(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 feit 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 (approximation not valid). 3) THER revised 9 2 98 Page 3 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Addre$s: 16 Kettle Hole Road:, W. Barnstable , MA Owner: Michael Princi Date of Inspection: D. SYSTEM FAILS: You mu indicate either "Yes" or "No" to each of the following: have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this termination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes N Backup-of sewage into facility-or system component due to an 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 1/2 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 Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a 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 I 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E. LARGE SY TEM FAILS: You must indica a either "Yes" or "No" to each of the following: The fo lowing criteria apply to large systems in addition to the criteria above: The s stem 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 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) The owner or op ator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the D rtment for further information. revised 9/2/98 Page 4of I • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 16 Kettle Hole Road', W. Barnstable', MA Owner: Michael Princi Date of Inspection: 3 0 o 1 Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes No / _ Pumping information was provided by the owner, occupant, or Board of Health. V — 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. _ As built plans have been obtained and examined. Note if they are not available with N/A. _ The facility or dwelling was inspected for signs of sewage back-up. l� _ The system does not receive non-sanitary or industrial waste flow. _ The site was inspected for signs of breakout. All system components, excluding the Soil Absorption System, have been located on the site. _ 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: _ Existing information. For example, Plan at B.O.H. _ Determined in the field (if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) [15.302(3)(b)1 _ The facility owner(and occupants,if differeni from owner) were provided with information on the properinaintanaaca of SubSurface Disposal Systems. revised 9/2/98 Page 5of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Orop"Address: 16 Kettle Hole Road., W. Barnstable , MA Owner: Michae� inc1 Date of Inspection: 3 FLOW CONDITIONS RESIDENTIAL: Design flow: 6J Og.p.d./bedroom. Number of bedrooms(d�gn):�' Number of bedrooms (actual): Total DESIGN flow Number of current residents: O Garbage grinder(yes or no): � Laundry(separate system) (yes or no)A/0; If yes, separate.inspection required Laundry system inspected (yes or no) Seasonal use (yes or no):L 0 Water meter readings, if available (last two year's usage(gpd): no tOWn Water Sump Pump(yes or no):_,LA- C1 Last date of occupancy: 9`j COMMB CIAL/INDUSTRIAL: Type of stablishment; Design fl w: qpd ( Based on 15.203) Basis of d sign flow Grease tr p present: (yes or no)_ Industrial aste Holding Tank present: (yes or no)_ Non-sanit ry waste discharged to the Title 5 system: (yes or no)_ Water m ter readings,if available: Last dat of occupancy: OTHER-(Descr'be) Last occupancy: GENERAL INFORMATION PUMPING RECORD,end source of information: System pumped as part of inspection: (yes or no)xc < If yes, volume pumped: ,O-t� U gallons Reason for pumping: GyGc� .S U 3 TYPE OF!YSTEM 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 2 APPROXIMATE AGE of all components, date installed(if known)and source of information: ✓ V Sewage odors detected when arriving at the site: (yes or no)'Ib revised 9/2/98 Page 6ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 'rop"Address: 16 Kettle Hole Road , W. Barnstable , MA owner: Michael Princi Date of Inspection: Z—1 c] BU DING SEWER: (Loc to on site plan) Depth elow grade:_ Materi I of construction:_cast iron_40 PVC_ other(explain.) Distan a from private water supply well or suction line Diame er Comm nt . (condition of'oints, venting, evidence of leakage,etc.) SEPTIC TANK:_ (locate on site plan) Depth below grader Material of construction: concrete_metal_Fiberglass _Polyethylene_other(explain) If tank is metal, list age_ Is.agegconfirmed by Certificate of Compliance_(Yes/No) Dimensions: �, `� `, ' 74, �s Sludge depth:__ Distance from top osludge to bottom of outlet tee or.baffle:-V-13— Scum thickness: 0 , Distance from top of scum to top of outlet tee or baffler ` )i Distance from bottom of scum to bottom of outlet tee or baffler How dimensions were determined: .t-S 'omments: {' (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity evidence of Jeaka+, c ® O $ ! N- 1� �+ .5 ►�� .a /C C'� L�- ►�C G G415 SE TRAP: (h a on site plan) Depth low grade:_ Material of construction:_concrete_metal_Fiberglass _Polyethylene_other(explain) Dimensio s: Scum thi Hess: Distance om top of scum to top of outlet tee or baffle: Distance f om bottom of scum to bottom of outlet tee or baffle: Date of la t pumping: Commen (recomm ndation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidenc of leakage,etc.) revised 9/2/98 Page 7of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) 'ropertyAddress: 16 Kettle Hole Road., W. Barnstable , MA Owner: Michael Pr�nci Date of Inspection: SS Ti OR HOLDING TANK: (Tank must be pumped prior to, or at time of, inspection) (local on site plan) Depth elow grade:_ Materia of construction: _concrete_metal_Fiberglass_Polyethylene_other(explain) Dimens ns: Capacit gallons Design ow: gallons/day Alarm resent Alarm I vel: Alarm in working order: Yes_ No_ Date o previous pumping: Comm nts: (cond• ion of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX:_ (locate on site plan) Depth of liquid level above outlet invert: O Comments: (note if level and distribution is eq al, evidence of solids carryover, evidence of leakage,into or out of box, etc.) - PUMP HAMBER:_ (locate n site plan) Pumps i working order: (Yes or No) Alarms n working order(Yes or No) Comm nts: (note ondition of pump chamber, condition of pumps and appurtenances, etc.) revised 9/2/98 Page 8of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 'rop"Address: 16 Kettle Hole Road;, W. Barnstable;, MA Own": Michael P inc i Date of Inspection:3_��j— SOIL ABSORPTION SYSTEM(SAS):_V (locate on site plan, if possible; excavation not required, location may be approximated by non-intrusive methods) If not located, explain: Type: leaching pits, number:_ leaching chambers,number: leaching galleries, number:_ leaching trenches, number, length: leaching fields, number, dimensions: overflow cesspool, number:_ Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure, level of�ponding, damp soil, condi ion of vegetation, etc.) CESSPOOLS:_ (locate on site plan) y' Number and configuration: 2yo Depth-top of liquid to inlet invert: Depth of solids layer. )epth of scum layer: Dimensions of cesspool: Materials of construction:. Indication of groundwater: inflow (cesspool must be pumped as part of inspection) Aent s: dition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY:_ (locate on site plan) Mater' Is of construction: Dimensions: Dept of solids: Com ents: (note ondition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) revised 9/2/98 Page 9ofII i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ' PART C SYSTEM INFORMATION(continued) , Nop"Address: 16 Kettle Hole Road., . W. ,Barnstable,, MA )wner: Michael Prsi�nci Date of Inspection: 3-0-9 / SKETCH OF SEWAGE DISPOSAL SYSTEM:- include ties to at least two permanent reference landmarks or enchmarks locate all wells within 100' (Locate where public water supply comes into house) JL i xF � revised 9/2/98 Page 10ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ' PART C SYSTEM INFORMATION(continued) ropertyAddress: 16 Kettle Hole Road., W. Barnstable , MA Owner: Michael Princi Date of Inspection: 3•-1-7 Q NRCS Report name Soil Type_ Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to Groundwater 1 Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record 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 Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) �L B � ✓1o/L� revised 9/2/98 Page 11of11 j -1 f j 1 ASSESSORS MAP NO:—� 1 Y s . PARCEL NO: — /9' No . Fiz$ �.�.._.... . ` THE COMMONWEALTH OF MASSACHUSETTS } BOAR® OF HEALTH --ID C_'U --------------0F....04P4�7.T .6. _.... Applirtttion for Biiipaa al Workii Tomitrndiun runtit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal S stem at: _. _ o Uon- dress - or Lot No ............. . !J._.`� �' ` _L- Od 6/ i(..•.... -•----••----------------------------------------- -caner a ....... Installer Address Q Type of Building Size Lot................•_.. ._...Sq. feet aDwelling—No. of Bedrooms............ .............................Expansion Attic ( ) Garbage Grinder ( ) pi Other—Type of Building of persons.........V.............. Showers ( — Cafeteria - i��l ( ) Other fixtures .l`� � ? fir f 'v`> '-¢ wDesign Flow.........,kO.........................gallons per person Per day. Total daily flow._._.�� .........................gallons. WSeptic Tank—Liquid*capacity/ZW.Pgallons Length..... ......... Width........ Diameter---------------- Depth................ x Disposal Trench—No..................... Width...... ............ Total Length................... Total leaching area....................sq. ft. Seepage Pit No..__... . f--- -- Depth below inlet...��..A........ Total leaching area..��../.._.... q. ft. �----------. Diameter------ ----- - s Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................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........................ ---- --------------------------------------•---...-•----....-------------•---- -------....-----•-•----------------•----------..-..------••----•-• ! ,` �-Description o oLr_ ---. x x -----------•-------------------------------•-------------•-•-----------•------------•-•--•--•••--------••------•-••••---••-------------...%..-------••--••--- U Nature of Repairs or Alterations—Answer when applicable__ k e_-rLgi ..... ............................. ....-....................................••----------------------------------------•--------.......----•---...---------------------•-----------------------...-----•------------------............--... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of L i:i:c. p 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 4by4ithVo ard of health. Signed. ` " .......... ....... - - ----- Date Application Approved By............ ... . -------------------------------- .................... Date Application Disapproved for the following reasons---------------•--•------------------•--•--------------------•--------------•-------------...--••--••.....•----- ...........-..................................................................................................................--•----------------------------------------------------------------------- Date PermitNo....'--2...-... .1!-.1---------------------- Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ........................I................. --------.............................................. -----_ ------ _- Appliration for Bi_qpaaal Works Tomitrurtion r.unlit Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal Z S stem at �V14 ........................................................................................... .................................................................................................. or Lot No. ................................................................ ................................................................................................. Owner . .....17 Install'er--------*---------**................. ............................. AA-ddresss ddress ................................. Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms........... ..............................Expansion Attic Garbage Grinder P4 Other—Type of Building 4!�-fWiP.Z' '2T14o. of persons........ ............... Showers (Z-) — Cafeteria Other fixtures ......... ........... ...... .................. .. Design Flow......-Po...........................gallons per person per day. Total daily flow----- .........................gallons. P4 Septic Tank—Liquid capacit/VYP.gallons Length-__-- ..... Width.... .......... Diameter._----_--.__---- Depth.........._..... Disposal Trench—No. .................... Width................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No------/------------ Diameter jk..r__ .... Depth below Total leaching areag.�/........sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit................._.. Depth to ground water........_............... f� Test Pit No. 2................minutes per inch Depth of Test Pit.........._......_.. Depth to ground water........................ ....................................................................................................................................................... 0 Description of Soil- ................ -------C...r?e... 5 ........................................................ x -------­----------------------------------------------------- ---------------*-------------------------------------------------------------------- --------------------------**---------- ....................................................................................................................................% ---------­--------- --------------------------------- U Nature of Repairs or Alterations—Answer when applicable.A>? /6 C�' Jp cz - ------------ ..................................................... ........................................................................................................................................................................................................ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TLIT LEi 51 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 th- board of health. v I Signed..............�2,' vyA,,,, 61 ...................................................... ---z,3 7 ... .............. Date Application Approved By........... ......................... .............. 5" Date Application Disapproved for the following reasons:................................................................................................................. ......................................................................................................................................................................................................... Date PermitNo.....IL-2------- ....................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ....................... ......................!�....... ......._OF......I)- ­z­', ......................................... TwWrtifiratr of TOmpliatta THIS IS TO CERTIFY, That the ndividual Sewage Disposal System constructed or Repaired (N-) by............. ....... ................................................................................................................... Installerat_-_Lnl----Y-..A------ .... ............. ............................................................................................................. has been installed in accordance with the provisions of TITIE 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 YHE SYSTEM WILL FUNCTION SATISFACTORY. DATE................ ..................................... Inspector... ---------------------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...........0 F....... ............................... —7 N 0.. FEE..Z...t)..... Disposal Vorkii T.Donstrudion rantit , "'j"k Permission is hereby granted....... ... .........fl..........Qo-w-( ................................................................................... to Construct or Repair S�) an Individual Sewage Disposal System a�'f Lc.........................Liz)............................................................................................... at No........ ........1, , I ?" 111,111 �-' Street r as shown on the application for Disposal Works Construction Permit Nokl_:..!>r(l Dated.._._____.... .................. ...d-" N I I ..................... Board of H-ealth*... rj'I ATE................................................................................ FORM 1255 HOBBS & WARREN. INC., PUBLISHERS Y p u PARCEL NO:- . n /91 THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .c" .....:........oF....j .............................. Appliratiau for Disposal Works (Qoustrurtion Permit Application is hereby trade for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: L-c!:�.�4C/�...._IL,E�`1:C�i�i�GE..�A..__._ _Gv__. 13�1 R�ys_;�r��9:...__..._»--- -- -----• o<I,a No. - ... . Owner �11.7.-et 1....... Ingeller Add—. Type of Building Size Lot............................Sq.feet Dwelling—No. of Bedrooms............1.............................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building .l-u!.V_.0 ''14 of ersons......... .............. Showers Cafeteria Other fixtures.5,'/.!1de.J......I eKt?:F !.l }.................................•--............................... {{�r� Design Flow........11V......................._..gallons per person p�r�ay. Total daily_flow.....4.9d........................gallons. W Septic Tank—Liquid capacitylllV..Dgallons Length..... ...........Width..... ........Diameter................Depth................ Disposal Trench—No.....................Width.....��yy.............Total Length...............j..Total leaching area....................sq.ft. 3 Seepage Pit No ..........Diameter..lo..�..A..... Depth below inle4»1:�.........Total leaching area..O.r/ sq.ft. z Other Distribution box( ) Dosing tank( ) aPercolation Test Results Performed by.....:.................................................................... Date........................................ a Test Pit No. I................minutes per inch Depth of Test Pit....................Depth to ground wnter........................ Es Test Pit No.2................minutes per inch Depth of Test Pit...................Depth to ground water........................ a .........................................................................._..._.................................................................. O Description of Soil..jr . !:§:1..t.�-..T:1....<Cir R ��... / !:..Q................................................. .................................................•---...................................._..»..................................................................----...........................--•----- ..�,yy.................................- .............. . Nature of Repairs or Alterations—Answer when applicable....^T..(1.�.f... CO!4c!�....v.f.�.............................. .........................._......»...................................................__......._...._»........................................................................................... 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 1by th boarrdyoff.health. / �[ / 7 Signed.<::11 Z_�.-:.=..i.!.:.-.`....—.—............. '€:l...,3/ .... Date ApplicationApproved By............ ... ..r,.......:.. ..............................._ ....................n.«... Application Disapproved for the following rearons:......................._....................................................................................._ _.................................................................................-.-_-.-------.._...—.._..............................--•----------•--.............................-- Date Permit No..... ..1...-»`f.S 3_.._...__, Issued--.........................»»... ._ .._ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .�%-z.an. tl ...........................:...........OF...... ......................._................ Tertifirute of Tomplitutre THIS IS TO CERTIFY,That the Individual Sewage Disposal System constructed ( ) or Repaired (V) - 1 Tdl. .Innalln ..........................................................................................._ has been installed in accordance with the provisions of TITLE 5of The State Sanitary Code as described in the applicltion for Disposal Works Construction Permit No.....a....1....:...yC..J......... dated................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT YHE SYSTEM WILL FUNCTION SATISFACTORY. DATE........... .'.1...'..$..7................. __— Inspector...- .�steer..:-........................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH r _ •�. h..........OF. �.?.`t.:.a..a_e :.. / r -7 FEE 13isposat Works (dollstrurtiou Permit Permission is hereby granted..._N.-#.... ?...... ..........................................................»__-_ to Construct ( ) or Repair (k) an Individuak Sewage Disposal System atNo......»L..'.y...Y.. +_......1.:.:..l:1.F�.:Sr..4�.. !.a:....__._J,11..r..... '.?.a::L.............................................................. seen ,- as shown on the application for Disposal Works Construction Permit Noi!.:..\Y�. .Dated.:....................................... Bab of Nedth DATE........................................................................---- FORM 1255 HOSES S WARREN.INC..FUELISHERS The attached are true copies. (Also this copy.) C• 1h1L Thomas A. McKean Director of Public Health RRl � r Jv�kIN �T Fa eOK N� mNIC. M SS • 0' ~I '.bNW • LONsuL.nNb 5F16�N � . 1-7 5�r�wnµltc.�+ Mrs t� �� ��- 5� �b 77v1�-r'I • • � � v`�N 0411, p LA o W. M ` 3 ,c I I p 330 G P�• .c 1 ors"�} d•+' Ai t �Z vR s rON� 1 5GTiVt3 t5#'7i+ �o•o c r 1 spa►clT`f = 1r-c 10 -1•r,c � � t•v I Oro rho , - ��'�- �T� -ry � GcNs;}�-icy? �► c, r 5 ry g'�•OO �3.75 T-,44 W- MrvttAl ar io•o �� n �� t pat: ptt tL• $b•oo • sl'o ,PIn1t 2 I� 514 NO Vik Nv t 2„ �I L• I �, � 10 , �l�V� D R �••� . Lh/•�PI f� a�hNt4�•3cFX v� -72at .3 / ALA' Q 1 IK f 33 ry sALF � • 4 PPP_ wy OFFICE OF i 0AHasTesLt, : s MA60. BOARD OF HEALTH .� aj °A i639' � 397 MAIN STREET 0 N AY k' ----- HYANNIS, MASS. 02601 July 19 , 1979 Mr. Michael, J. Princi Attorney at Law Ten East Main Street Hyannis, MA. Dear Mr. Princi: Thank you for appearing before us on July 18, 1979, in regards to your variance request. You are granted a conditional variance to install a well 125 feet from the septic system in lieu of the required 150 feet pending approval of your on-site sewage disposal plans. All other provisions of Title 5, State Environmental Code, and the Town of Barnstable Health regulations must be complied with. The Board thoroughly supports innovative ideas and projects designed to conserve energy. V r truly your , Ober L. dhflcls, Chairman A. W. Mandelstam, M. D. GJLJ� Ann Jan Eshbaugh BOARD OF HEALTH TOWN OF BARNSTABLE k7MK/mm _ 1 TOWN OF BARNSTABLE CATION poi f!� 6�E��� SEWAGE # VILLAGE C9� ASSESSOR'S MAP & LOT G G/ INSTALLER'S NAME & PHONE NO."R'!/fir- y�r�. SEPTIC TANK CAPACITY/CX-3 LEACHING FACILITY:(type) �p NO. OF BEDROOMS J PRIVATE WELL_ OR PUBLIC WATER/-u �=/. BUILDER OR OWNER DATE PERMIT ISSUED: DATE .COMPLIANCE ISSUED: I/ VARIANCE GRANTED: Yes No 4 70 A �' �v E;.O .P (rD & O6 L0tATION � �/ SEWAGE PERMIT NO. L o t J4 Iq K f 7`7-L E h`o lfz� VILLAGE liter FST d /F S 7-112,6 L E INSTA LLER'S NAME i ADDRESS ToleIwo g&o S -& �- /1/4f2/�, e U I L D E R OR OWNER C', cppPMFp M DATE PERMIT ISSUED Cf- DAT E COMPLIANCE ISSUED i 1417 No................ Y F ..................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ........TPWN.................OF...............BARNSTABLE ........................................................................... Appliration for Disposal Works Tonstrumon- Frrutit Application is hereby made for a Permit to Construct ( or Repair an Individual Sewage Disposal System at: Lot 4A Kettlehole Road West Barnstable, Massachusetts ................................................................................................ ...............................................Barnstable,___Massachusetts_ ........... ....... Location-Ad�ess. or Lot R7 Michael & Margaret rinci 1201 Scudder Lane, Barnstable 02630 ................................................................................................ .....................................................Lane, _Barnstable 4.L1 caner Addros ............tlA.... ...... 1Vy I t...................................... Installer Address Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms.._........................................Ezcpansion Attic Garbage Grinder ( Other—Type of Building W0.0d---Frame No. of Mvms....3------------- Showers Cafeteria ( 5 Sinks _(Kitchen and Bathroom) Other fixtures ... Sinks. ... ............ ............................................................ ------------------------- Design Flow............................................gallons per person per day. Total daily flow..............3.3.0......................gallons. 04 Septic Tank—Liquid capacityl.0-O.Q.gallons Length....5.......... Width.....8........ Diameter................ Depth....__.._...._.. Disposal Trench—No. --J............. Width.........8........ Total Length.........8......... Total leaching area......fa-A........sq. ft. Seepage Pit No------------ ------- Diameter.__..-_-._--.------. Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( X) Dosing tank ( ) — 1-4 Percolation Test Results Performed by---------Alan...W............................................... Date.....L.N!y.f----19i9.... Test Pit No. I---7�t.-Lminutes per inch Depth of Test Pit.....12........... Depth to ground water.N/A------------ Test Pit No. 2.......W.1-minutes per inch Depth of Test Pit......12........... Depth to ground water-N/A............... P4 ............................................................................................... ........................................... .... ......... 0 Description of Soil Fjrm Medium...to...ca a r ae...clean...s.anq,- a-vel—and....stane. .. ........... ...... ---- .41 ----------- ------------------------/ ----------- M. ------------ --------- 14 .................. U Nature of Repairs or Alterationsapplicable--N./A---------------------------------------------- ... ........................... ...................................................................... ............................................... ..................................... ........................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TL I Ti iE 5 of the State Sanitary Code— The undersigned further agre t to place the system in operation until a Certificate of Compliance has been i by the bo d of h Ith. See Diagram Sig ' d...... .... ....Pf . . ... .................I•........... .... /!77 V..qate�----- Application Approved By •.... . ...................... •...... Date Application Disapproved for the following reasons:............................................ ................................................................... ......................................................................................................................................................................................................... Date PermitNo......................................................... Issued....4............Date.....7.f.................. 1 No............ .._ FEs... ..._............ THE COMMONWEALTH OF MASSACHUSETTS 1-. BOARD OF HEALTH ----......TOWN..........:......OF............1�,ARI`TS.2'ABLE..............-----------..................... Appliration for Diopos a1 orks Tumitxnrtion• ramit Application is hereby made for a Permit to Construct ( X) or Repair ( ) an Individual Sewage Disposal System at: .Lot 4A Kettlehole Road „West Barnstable,--Massachusetts ......_.. . ..............................•------------.......----••-------------- ----- ----•------------------ Location-Address• or Lot No. Michael & Margaret Princi 1201 Scudder Lane, .Barnstable 02630 ............................. ........... -••---•--•-••-••-••-- ••...................... ........•- s Owner Address a ' ' .. ........:_.,. ......i� -�t�R w►?---------•- -•..............................•---------.......-----•----.....------.....-------•-----•--....... Installer Address QType of Building Size Lot-------------------- -----Sq. feet U Dwelling—No, of Bedrooms..........................................Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building Wood--Frame No. of oms 3 Showers — Cafeteria OPL4ther fixtures ...5__Sinks__._(Ki;tchen_an_-__,Bathroom).............................._,,,,,____________.._.......__ * Design Flow............................................gallons per person per day. Total daily flow.___... .._..... gal W330 Ions. W * Septic Tank—Liquid capacityl_Q.Q.Q.gallons Length.......5��__._ Width..... _ _--__- Diameter................ Depth................ x DispoIL sal Trench—No. ----------1..._.... Width.........8._........ Total Length......... ........ Total leaching area.._.._61....._..sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box (X, ) Dosing tank ( ) ,. `-' Percolation Test Results Performed--by, Alan W. Date__l May,,,_19 7.9....... Test Pit No. 1.... ...minutes per inch Depth of Test Pit-----la......... Depth to ground water...N,/A........... f=, Test Pit No. 2..... 0;,-minutes per inch Depth of Test Pit--___a_2'...._.. Depth to ground water--._1��A__.._..____ a =••-•-----•--••-••-•-----------•••-•.....-•------------------------------•---••-•-••-••.............................................................. Description of Soil....Firm medium to clean sand, graveland stone V ------------ -...... ------• ----- - W .................... ----- ---•---- -• --•- ----•-•• •. -•-• -••----- ------. ........ .------•-- -••-••......-----.• ------- -- ----- ---------�r --------- U Nature f eP s •.11 t r I�"rnI�Iieable N�A ,w. = --- ---_...• ••...... ••-•-••••---------••------------•--•--•-----------•••-----•-•---••--••••.....................•----- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the°provisions of iITL L 5.of the State Sanitary Code—Tl`e:undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. * S-ee Diagram _ __Si ied - • Prl --------------- -- --•-- ------....Da•.............. e�1aeY J. ncl Date Application'Approved By..... . . ..... 7 ; Application Disapproved for the following reasons: ________________________•______._._____._.__..____.___._._•-------•----- Date � •••••--•-- ........................ ------.......................... -••---......--•-------••-----••.... -----...---•-- Date PermitNo......................................................... Issued....................................................... xy: Date e' "•f,'r'' THE COMMONWEALTH OF MASSACHUSETTS ` 4, BOARD Z HEALT ..........:OF........ .........`........ (In ifiratr of TompliFanrr THI I 0 C IF at the Individual Sewage Disposal System constructed ( ) or Repaired ( ) r , l b - �--_ all 1 _ (+� at.....�}...... � # �- ......--•-•-. .19 ----- ----- ----- ............................................ ---------- ------ has been installed in accordance with the provisions of T r f T e State Sanitary de �dejcy�ed 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 'P DATE............/?........... ... ��:.. Inspector ,,.N," ............................. THE COMMONWEALTH OF MASSACHUSETTS " BOARD OF HEAL �. .......OF..... .. ... No......... #?..... FEE......................... !-!a t r � o�nr#ion rranit Permission i reby granted----:--. ----=-------- ------- .- • '-- to Constru it ( or Repair,( ) in $Idi vidual S pos G1 at No.... ........ ° Street �j/� as shown on the application for Disposal Works Construction it N Board of Health = DATE-- ....... . ............................. FORM 1255 HOBBS & WARREN. INC., PUBLISHERS yj 4 j oFTHE To� TOWN OF BARNSTABLE � y OFFICE OF i BAH MASS. E, : BOARD .OF HEALTH y A88. p, pp 1639. 6� 0 MPY k� 397 MAIN STREET HYANNIS, MASS. 02601 July 19, 1979 Mr. Michael, J. Princi Attorney at Law Ten East Main Street Hyannis , MA. Dear Mr. Princi: Thank you for appearing before us on July 18, 19791 in regards to your variance request. You are granted a conditional variance to install a well 125 feet from the septic system in lieu of the required 150 feet pending approval of your on-site sewage disposal plans. All other provisions of Title 5, State Environmental Code, and the Town of Barnstable Health regulations must be complied with. The Board thoroughly supports innovative ideas and projects designed to conserve energy. U r truly your , ober L. niftcTs, Chairman A. W. Mandelstam, M. D. c Ann Jan Eshbaugh BOARD OF HEALTH TOWN OF BARNSTABLE 'JMK/mm ��� fly h r t i s"I==:�•_.T ____-� ... IBM-) exz- ails � T , 17 d�Z:T �v ze- /t' ALA,- %' 1 AL i i r PFr ,�' J 1- `Y -FrT eoK 307 V1. .joNP6 �oNsu�-f1N� �• . 5r•46°It� iu . 5Ei'�T�nWt 1-7 10)7e) PNO -717v1'�' -Pz 41 iQl-t� — VO� 72ot — I � 0 z pow o � i�� N.aY•1 a 3 � I I D �330 G•P P• - 10NA1 E v17f"'}T Y/Z pir S�TOI�i 5N\JiPWN AA f . BJ�• o - 171�1'ri, t�oX ow A Irk �, 'cF'µ�•t-c. /`— G�aaN t� 9JR ':t-• eJr�. . v � Aft- l�tl• O i NV. G I Nq• �4 v •�3.75 i� ��, ao 3 +o•o L r act t�T. �(.. gb•00 _ F prWfi6tsEh B3•� •, - L-Ala�c Ar Wo611tz,PD0`-CTPl �S it n NO WN-rW - No._. ....... -'.1 � THE COMMONWEALfiH OF MASSACHUSETTS w BOARD OF HEALTH .............. OF.,.•,., BARNSTAB .� Iirtttioit for Aspoottt lorko Cnoito#�•ixt i�r - �rrutt� Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: _ Lot•_.4A. Kettlehole Road & Location •Ad ess ~•-•~•--••• ...West„Barnstable, Massach Michael Mar aretrinci ....................._ ......._.......•---...... 1201 Scudd or Lot No. usetts........ W wner •.................................rLa-ne, Barnstable 0263 Addres - r...---- .........-- �.�.f -. Installer ........C.....Ad"`Tess 4 ............. U Type of Building -••--•--•.-.... �-+ Dwelling—No. of Bedrooms........................... Size Lot............................Sq, feet •............ ...E ansion Attic Other—Type of Building hip.Od._.Frame No: ofj Dios, 3 ( ) Garbage Grinder ( ) * 5 S1 6� "" ••• Showers (2 ) — Cafeteria ( ) Other fixtures ..............nks Ki chen... id,Ba-�,Ylrgo�)- W Design Flow.... 111ons w.......... .......... ...................... ........ ................................... ..•-g• per person per day. Total daily flow..............�.3Q......................gallons. W * Septic Tank—Liquid capacityl.0.60.gallons Length....5...•._•• Width..... Diameter......._.•...... Depth................ Disposal Trench—No, - Width.........13..'. "' •..... Total Length........R.....,••_ Total leaching Seepage Pit No...._..._ .. g area.-....Fi4..._.--_sq, ft. •-••--•• Diameter.................... Depth below inlet..._................ Total leaching area.............__...sq. ft. Other Distribution box X -+ ( ) Dosing tank ( ) Percolation Test Results Performed b ................... Date.....L.AgY.r....._......... Test Pit No. I...ft .... minutes per inch Depth of Test Pit......12.1....... Depth to ground water.N/A_........... Test Pit No. 2....."d".1 minutes per inch Depth of Test Pit.....,],2'-•••_-• Depth to r ................••••-..........••-- � Description of •................................................•------- Dun water. ---......._... P Soil_ .FirM.-Medium...to..cnarse..clea . --- �......... . asze stnize ? ...............-.. t. Q...,.. ..f /..................... ......S Nature of Repairs or Alterations— ' ..................... nswer w en applicable...11T/ . Agreement: .............................A.. .......................:........".'.'-.......................... 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 a re operation until a Certificate of Compliance has been i by the bo d of li ith. g t to place the system in * See Diagram Slg a ...... Application Approved B </ ..... -let Application Disapproved for the following reasons:..... ...... ...Da i e ....... ................... ......................... .............._/.�;.. ....... ........~Da" •-..... Permit No ..._-•---•-----•-----..~.... Issued.... 1...i_r. D: at - I i _M.M. x THE COMMONWEALTH OF MASSACHUSETTS BOARD O :HEALT .. Tertif irate of Toutphaurr THI I O IF at the Individual Sewage Disposal System constructed (�or Repaired ( ) / .....,..."'......./,/.�`TA. . t..�1l.Q ............. .........•. -....... ._.......... by....... .............. . - ----_---••. a yA,��..� ... ......_tY 1� at.....M. ..... ,��.h. .......... .........W.... ......... ....................I................ has been installed in accordance with the provisions of T r f T e State Sanitary e c ' ed in the application for Disposal Works Construction Permit No... ..................................... dated........�r: �...J.. `................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE .CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. 2. Inspector. Z j4A' : —5 °as 2t:r�Y DATE............./.............................{.............. `>ti. P ..............._........... THE COMMONWEALTH OF. MASSACHUSETTS BOARD O/�HE � � •7� .......OF.... L� .. ........... ..................................... ... 3G�--"� ...`. ;.. No.... FEL........................ �9io roott(( r otrurtiott an ...... . ....... ......._.... P rmission i reb ranted.....���� ....... . = �/ e yg � to Constr I t ( or Repair,( ) n �divirl al S pos Sy ecat No..... c. ... IX.!..... ........_..... /.`..G..l.!.............. � ........ -• --....... street �'.. as shown on the application for Disposal Works Construction i.t y� -•-•--•••-- •••.._.___--•• ............ / Dated 5 ................ t� 1 Board of , DATE. ...1. 1...L •r��•-.. . .......... {'. FORM 1255 HOBBS a WARREN. INC.. PUBLISHERS iL 40 •�:��� ��. ter - JJ r i r — ' TOWN OF BARNSTABLE Y. UNDERGROUND FUEL AND CHEMICAL STORAGE SYSTEMS ASSESSORS MAP NO. o 9 PARCEL NO. 03 ADDRESS; ��'7 7C4% '�/1(J/�, nt��(C VILLAGE: M,0 t7AME',..... �' /GQyI..-,.-. CONTACT PERSON PHONE NUMBER .3 S y LOCATION OF TANKS:_ CAPACITY: ..TYPE- OF" FUEL• AGE: TYPE: LEAK { f OR CHEMICAL%t DETECTION 05 yoil 1�0 Q t¢ ©t3�C� /®®C7 ~Ll I dl�S�l ' to SYSTEM! 4am s(wee -on r h4 side DATE OF PURCHASE OF EACH: 1. cp 75 2. 3. 4. S. DATE OF FIRE DEPARTMENT PERMIT: TESTING CERTIFICATION SUBMITTED: PASSED DID NOT PASS PLEASE PROVIDE A SKETCH SHOWING THE LOCATION OF TANKS ON THE BACK OF THIS CARD. :S2 f D+c �G t3 �P3 -1Qh k •,� STATEMENT I WILLIAM R. DAVIS 50 Marstons Ave. GATE 0-7 HYANNIS, MASS. 02601 I Phone 775-7628 I PLEASE DETACH AND RETURN WITH YOUR REMITTANCE INVOICE NUMBER/DESCRIPTION CHARGES CREDITS BALANCE BALANCE FORWARD • {t i ! i i � 4 WILLIAM R. DAVIS PAY LAST AMOUNT // IN THIS COLUMN 7 L_