HomeMy WebLinkAbout0196 KETTLEHOLE ROAD - Health 96 Kettlehole Road
Barnstable
A = 110 012
f
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:
196 KETTLE HOLE ROAD
Please specify well type: Building Lot#: Assessor's Map#:
Domestic — 1 110
Assessor's Lot#: ZIP Code:
Number Of Wells: 012 02668
City/Town:
Well Location BARNSTABLE
In public right-of-way: GPS
G Yes r No North: West:
41.71442 70.39627
Subdivision/Property/DescripUon:
Mailing Address:
dick here if same as well location addres
Property Owner: Street Number: Street Name:
ROBERT SPAULDING 196 KETTLE HOLE ROAD
City/Town: State:
Engineering Firm: ABINGTON MASSA:HUSETTS r-"
ZIP Code:
02668
Board of health permit obtained:
r Yes t) Not Required
Permit Number: . Date Issued:
W2014 002 1314r2014
C
CD
J_— y
r�
Massachusetts Department of Environmental Protection
Bureau of Resource Protection—Well Driller Program
Well Completion Reports(General)
Well Driller - General Well Form
DRILLING METHOD
Overb_ur_d_en Bedrock
uger --Choose Bedrock WELL LOG OVERBURDEN LITHOLOGY _
From Drop in drill 'Extra fast or slow,;Loss or addition of
To(ft) Code Color Comment
(ft) stem ,,drill rate fluid
0 20 IFine To Coarse Sand Brown 0 YES r ND 0 Fast 0 Slow 0 Loss 0 Addition
20 40 Fine To Coarse Sand Brown r YES NO C) Fast 0 Slow - Loss ( Addition
40 60 IMediumSand 113rown 0 YES r NO I C) Fast G Slow 0 Loss 0 Addition
60 8p Fine To Coarse Sand Brown YES NO Fast 0 Slow fJ Loss �Addition
WELL LOG BEDROCK LITHOLOGY
Visibie yExtra
From Drop in drill Extra fast or slow Loss or addition of i
To(ft) Code Comment Rust ';Large
(ft) stem drill rate fluid -
:Staining !;Chips ;
Choose Code r r NO Fast Slow fJ Loss Addition Ye �Ye
YES
ADDITIONAL WELL INFORMATION
Developed r Yes r No Disinfected r Yes G No
Total Well Depth 80 Depth to Bedrock
Fracture
Surface Seal Type
None Enhancement Yes G No
CASING I r Is Casing above ground From: 1 To: 0
From .To iType Thickness Diameter Driveshoe
0 77 lPolyAnyl Chloride Schedule 40 4 []Ye
SCREEN r No Scree
From To Type Slot Size ,Diameter
77 80 IStainless Steel Well Point 10.012 4
WATER-BEARING ZONES ❑DRYWEL
From To Yield(gpm)
59 80 10
PERMANENT PUMP(IF AVAILABLE)
2 Wire Constant Speed
Pump Description Submersible Horsepower 3/
h
Massachusetts Department of Environmental Protection
Bureau of Resource Protection—Well Driller Program
Well Completion Reports(General)
Pump Intake Depth(ft) 75 Nominal Pump Capacity(gpm) 10
ANNULAR SEAL/FILTER PACK
Water From To Material 1 Weight Material 2 Weight W ) Batches Method Of Placement
al
Choose Material Choose Material I --Choose One WELL TEST DATA
Time Pumping Time To
Recovery (ft
Date Method Yield(gpm) Pumped Level (ft Recover
(HH:MM) BGS) (HH:MM) BGS)
3/4/2014 lConstant Rate Pump 10 1:30 62 0:01 59
WATER LEVEL
Date Measured Static Depth BGS (ft) Flowing Rate(gpm)
3/4/2014 59 10
COMMENTS
WELL DRILLERS STATEMENT
This well was drilled or altered under my direct supervision,according to the applicable rules and regulations,and this report is complete
and accurate to the best of my knowledge.
Supervising Driller DESMON
THOMAS E Monitoring[M] III,
Signature
Driller DESMOND III Registration# 764 THOMAS,
DESMOND WELL
Firm DRILLING INC. Rig Permit# 023 Date Job Complete 3/4/2014
NOTE:Well Completion Reports must be filed by the registered well driller within 30 days of well completion.
n
"R'sr� CERTIFICATE OF ANALYSIS Page: 1 of 1
Barnstable County Health Laboratory (M-MA009)
`SfncHas€ Report Prepared For: Report Dated: 3/6/2014
Sally Desmond
Desmond Well Drilling Order No.: G1478880
P O Box 2783
Orleans, MA 02653
Laboratory ID#: 1478880-01 Description: Water-Drinking Water
Sample#: Sample Location: 196 Kettle Pond Rd.W Barnstable, MA Collected: 03/04/2014
Collected by: Customer Received: 03/04/2014
Routine M
ITEM RESULT UNITS RL MCL METHOD# TESTED
Nitrate as Nitrogen 2.3 mg/L 0.10 10 EPA 300.0 3/4/2014
Iron 0.070 mg/L 0.010 0.3 EPA 200.7 3/4/2014
Manganese NID mg/L 0.008 EPA 200.7 3/4/2014
pH 5.9 PH AT 25C NA 6.5-8.5 SM 4500-1-1-13 3/4/2014
Sodium 22 mg/L 1.0 20 EPA 200.7. 3/4/2014
Total Coliform Absent P/A 0 0 SM 9223 3/4/2014
Conductance 260 umohs/cm 2.0 SM 25106 3/4/2014
Sodium level is above the maxium contaminant level. Those on a low sodium diet may wish to consult a physician.
Attached please find the laboratory certified parameter list. Approved By: _yt � 4-0
(Lab Director)
f
ND=None Detected RL = Reporting Limit MCL=Maximum Contaminant Level
Superior Court House, PO.Box 427, Barnstable, MA 02630 Ph: 508-375-6605
CERTIFICATE OF ANALYSIS
Barnstable County Health Laboratory (M-MA009)
�3,y�4AC!lUS�%�
Recipient: Sally Desmond Matrix: Water-Drinking.Water
Desmond Well Drilling Sampled: 03/04/2014 14:00
P 0 Box 2783 Received: 03/04/2014 .15:55
Orleans, MA 02653 Collection Address: 196 Kettle Pond Rd.W Barnstable,MA
Order#: G1478880 Sample Location:
Description: 2day-196 Kettle Pond Rd.
Lab 1478880 Q1 Date Analyzed: 3/5/2014 @. 15:31
Sample#: Analyst: yn
Method: EPA 524.2 Dilution Factor: 1
Comment: Sodium level is above the maxium contaminant level.Those on a low sodium diet may wish to consult a physician.
EPA 524.2- Volatile OrganiCS by GC/MS
Result MCL MDL Result MCL MDL.
Parameter ug/L ug/L ug/L Parameter ug/L ug/L ug/L
DichlorodiFluoromethane NO I 0,50 Chloroform 0.73 80 0.50
.. ..._.
Chloromethane ND Q•50 cis-1,2-Dichloroethene ND 70 0.50
Vinyl chloride ND 2.0 0.50 cis-1,3-Dichloropropene ND 0;50
Bromomethane ND 0.50--j Dibromochloromethane ND 0.50
1,1,1,2-Tetrachloroethane ND 0.50 I Dibromomethane ND 0.50
1,1,1-Trichioroethane ND Zoo I 0.50 Ethylbenzene ND 700 0:so
1,1,2,2-Tetrachloroethane ND 0.50 Hexachlorobutadiene ND 0.50
1,1,2-Trichloroethane ND 5.0 0.50 1so ro (benzene ND 0:50
1,1-Dichloroethane ND 6.50 i Methylene chloride ND 5.0 0.50
1,1-Dichloroethene ND 7.0 I 0.50 MethylAert-butyl ether ND 0.50
1,1-Dichloropropene ND 0.50 Naphthalene ND 0.50
1,2,3-Trichlorobenzene. ND 0.50 n-Butylbenzene ND 0.50
1,2,3-Trichloropropane ND 0.50 I n-Propylbenzene - ND 0>50
. ....... . ...... - ---..._ _ .....
1,2,4-Trichlorobenzene ND 70 0.50 p Isopropyitoluene ND 0.50
1,2,4-Trimethyibenzene ND 0.50 sec-Butylbenzene ND 0.50
1,2-Dibromo=3-chloropropane ND 0.50 Styrene ND 100. 05o
1,2-Dibromoethane.(EDB) ND 0.50 tent-Butylbenzene ND 050
1,2-Dichlorobenzene ND 600 0.50 Tetrachloroethene ND 5:o 050
5.0 0.50 1000 0:5o
12-Dichloroethane ND Toluene ND
EI
1,2-_Dichloropropane ND 0.50 Total xylenes ND 10000 0:50
1,3,5-Trimethylbenzene ND I 0.50 trans-1,2-Dichloroethene ND 100 0.50 I
1,3-Dichlorobenzene ND 0.50 trans-1,3-Dichloropropene _ ND 0.50
1,3-Dichloropropane ND 0.50 Trichloroethene ND 5.0 0.50
1,4-Dichlorobenzene ND 5.0 0.50 Trichlorofluoromethane ND 0.50
--
2,2-Dichloropropane ND 0.50 ---- --_ D_-_-...._--.-___ -._..�- . o
Surrogates /o Recovered QC Limits(/o)
2-Chlorotoiuene ND 0.50 I
p-BromoFluorobenzene 93-1/0 70 130
4-Chlorotoluene ND 0.50 I 1,2-Dichlorobenzene-d4 96% 70 130
Benzene ND 5.0 0.50
Bromobenzene, ND 0.50
Bromochloromethane ND 0.50
Bromodichloromethane ND 0.50
Bromoform ND 0.50 i
Carbon tetrachloride ND 5.0 0.50
Chlorobenzene ND loo --- I
Chloroethane ND 0.50
Attached please find the laboratory certified parameter list. Approved By:(La -__-
b Director) a/ND=None Detected RL = Reporting Limit MCL=Maximum Contaminant Le el
Superior Court House, PO. Box 427, Barnstable, MA 02630 Ph:508-375-6605 Page 1 of
No. a 2— J
Fee
BOARD OF HEALTH
TOWN OF BARNSTABLE
2pplicattou _for Yell Cougtructtou Permit
Application is hereby made for a permit to Construct(�, Alter( ), or Repair( ) an individual well at:
1°1b
Location-Address Assessors Map and Parcel
R06UI r NaY.u, SPoA;1-V-V1k °\ Vdr,6 oft. i W= s 'u"kg 0�6�
ner Address
trn�, \4Q,� -k) Im 218 �d&A>r,g DM 02653
Installer-Driller Address
Type of Building / —,2
Dwelling V
Other-Type of Building No. of Persons
Type of Well Li" ,SOMb N'c Capacity lb t -y\
Purpose of Well RAdw-
7 r-3 O
�4
Agreement:
The undersigned agrees to install the afore described individual well in accordance with,th provisiof Sof the
C7)
Town of Barnstable Board of Health Private Well Protection Regulation-The undersigned further-agrees not jf place;dhe
well in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed )V
%ate'
Application Approved By D Z f
Date
Application Disapproved for the following reasons:
Date
Permit No. I/-/--j—O Issued
Date
------------------------------------------
BOARD OF HEALTH
TOWN OF BARNSTABLE
Certificate of Compliance
THIS IS TO CERTIFY,that the individual well Constructed 4, Altered( ), or Repaired( )
by 1JQS1m 9ryj\ Wk-\\ ���t\(r�1 JjY y,
� i` r_ y Installer
p\
at (o �t��Cl0 l� RL r� t 3(u n3law k-
has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection
Regulation as described in the application for Well Construction Permit No. Dated
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL
SYSTEM WILL FUNCTION SATISFACTORILY.
Date Inspector
o � 2 .r
No. t '
�` ,<� (yM;1f �.�ot jl ✓Y-e Fee
BOARD OF HEALTH
TOWN OF BARNSTABLE
01ppricatiou _for Yell Cougtructiou permit
Application is hereby made for a permit to Construct(�, Alter(`A or Repair( ) an individual well at:
J S WC.`Ao�#_ Z ,inl . i l o I m-
Location-Address ` Assessors Map and Parcel
V ch,Jl 2 u i)Ar .0
. W Psxk nsk<<.�_I x, nz(,�
caner'\ Address
Installer-Driller Address
Type of Building
Dwelling
Other-Type of Building No. of Persons
Type of Well y SC\AY b Ne, Capacity !u+ u11n
Purpose of Well lx 0MU -
71
Agreement:
The undersigned agrees to install the afore described individual well in accordance with the provisions of the
t
Town of Barnstable Board of Health Private Well Protection Regulation-The undersigned further agrees not to place,the
well in operation until a Certificate of Compliance has been issued by the Board of Health. '
Signed ,� W J
,-Date
u4 r �
Application Approved By rill. f ! S� /v�
Date
Application Disapproved for the following reasons:
Date
Permit No. I -1-2 U(L-1 -n 0 D Issued
Date
BOARD OF HEALTH
TOWN OF BARNSTABLE
Certificate of Compliance
THIS IS TO CERTIFY,that the individual well Constructed(✓ ), Altered( ), or Repaired(
by SV,,t7 a. \I\)Y\� \�c��\(r�� I'Y`c ,
Installer
at C\ VV��-�Ao Q _ � \t�� e^.e r,9�aw e
has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection
Regulation as described in the application for Well Construction Permit No. Dated
J
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
Yell Con.5truction permit
No. (jj 6 IV OU 2— Fee Y r
Permission is hereby granted to
Installer
to Construct Alter( ), or Repair( an individual well at:
No. 1 C\(o ns�nb1,�
Street
as shown on the application for a Well Construction Permit No. w d 0/V-00 Dated 3//�I/
Date /�/�(� Approved By 1,9��C i
cr"
eE7 2 r
AWA
ra�ru, E
f'l r
O yea
i I
4%
V Diii
"21
4$cxno
Co
eum~ �
CHI
co
ilk Lrg--
?C)QD
Y ;a
TOWN OF BARNSTABLE
LQ-tATION /'�� i � y9� SEWAGE #
V11LAGE s �� ASSESSOR'S MAP & LOT/I,Oi" 012,
INSTALLER'S NAME PHONE NO.
SEPTIC TANK CAPACITY /001
LEACHING FACILITY:(type) /pOp e (siZe)
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER
PIZ
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
6,
59 J
go
00,
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal
System at'.
ation-Address or Lot No.
Z Other Distribution box ( ) Dosing tank ( )
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code —The undersigned further agrees not to place the
system in operation until a Certificate of Complila 'e has be is>u�d bl,!)ie board of k ealth.
ApplicationApproved By ..................... - - - -------- --------7. . . ..... _ -----
� ---_---'---------------__-----'--'---__--_-----------_------' _—'—'��.----
� i P�nmr2�o `���- c� �so�6
� � --��—=---—'_�_�.--^------' -----~��--'~°'°—
� ~~
te
_____________________________________________________
FiEs......ao..........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF !-HEALTH
TOWN OF BARNSTABLE
Applirativit for Bi-tipb.9al Marks Towitrurtinn runfit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at: -
-�,/ o ation Address or Lot No.
......... ...... ._.....9?__.........................
.n ._Address ��.
nstaller Address
T e of Building Size Lot............................Sq. feet
Dwelling— No. o edrooms-_- i Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building No. of ersons____________________________ Showers
� YP g ---------------------------- P ( ) — Cafeteria ( )
dOther fixtures ----------------------------------------------------------------------------------- --- ---------------••----•••......-• ----••....
W Design Flow----------------------------_..............__gallons per person per day. Total daily flow--------------------------------------------gallons.
WSeptic Tank—Liquid capacity---:--------gallons Length---------------- Width---------------- Diameter................ Depth................
x Disposal Trench—No:.................... Width.................... Total Length-------------------- Total leaching area....................sq. ft.
Seepage Pit No._____-:............. Diameter-------------------- Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
a
Test Pit No. I................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........................
P4 -----------------------------------------------------------
•----------------------------------------
------------
•----------------
••-•--------
•...........
.••-
0 Description of Soil........................................................................................................................................................................
x
V
W ---•-------------------------------------•-•--------•-••------.......-----------•---•••......--•--••----....-- ---- .......
U Nature of Repairs or Alterations—Answ.r when p°In ble.__
- --- . .......•..•.�/11 .Al --__.
- �i �
...........
.... y� - ------- .....................................
Agreement:
The undersigned agrees to install the fforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Complia e has be issued by tke board of .ealth.
Signed .. . ............ ........ .. ---- - ----------- --- -------.-- ------- --- -
- �-��--�•�• Dace
Application.Approved By .................�J ....._ �..---�`� r..b.- ,, ----------------------------------------- ------ ...3.--c l..e./:'..��.4.-..
Application Disapproved for the fo-owing reasons- ----------------------------------------------------------------------------------------------------- -------------
--------------------------------------------------r-.-..................------------------------------------------------------------------------------------------------------------------.-
Da
((�� _ Dace
Permit No. --......?5.... �. .. .f. ....._y,y... Issued .Dare �� ��...�......
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Tertifir to of C11nmplian>re '
THIS IS T CERTIF , That t Individu Sewa Disposal Sys •m constructed ( ) or Repaired (v )
by ----------------------- - .. �- -...
at .. l - -- . r- -----------------------------------------.-..-..---- .
has been installed in accordance with the provisions of TITLE 5 of The State Environmental 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.
DATE..... .%.. � -.. -. Inspec or -...-
15Zy, _
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
g- TOWN OF BARNSTABLE Al-
N o..[ '.-. ..1., FEs_✓ :............
Billpalittl 101r To trudw ramit
Permission is hereby granted•••---•-• ••--•-•--• .... ... -- ......... .. f! ------------------------------------------------------------
to Construct ( ���rjeorair In.'vidu -2Se� eo alystem t
at No...l%_'.. - . ...------ = � f :..---
Street
as shown on the application for Disposal Works Construction Permit No. Dated_;;�'�1_........�7..............
..............................a.. ----------..............................................
Board of Health
DATE--.-...----- -----------------------------•--------------------------•----
FORM 38608 H0
8
83 a WARREN.INC..PUBLISHERS
i
AsBuilt Page 1 of 1
TOWN OF BARNSTABLE
LOCATION�Q� L� ei�P �'iSEWAGE #
VILLAGE — ASSESSOR'S MAP & LOT//41— 012-,
INSTALLER'S NAME & PHONE NO. ¢�
SEPTIC TANK CAPACITY
01
LEACI�NG FACILITY:(type) /r?p ,� (size)
NO. OF BEDROOMS—PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED: ,Z.l
VARIANCE GRANTED: Yes No
59 ;
50
D
o�
http://issgl2/intranet/propdata/prebuilt.aspx?mappar=110012&seq=1 3/4/2014
ti7
L0,{ /ATION SEWAGE PERMIT NO.
V 1 L'A G E
INSTA LLER'S NAME & ADDRESS
B UIIDE R OR OWNER
DATE PERMIT ISSUED �j'_ 7_ 7[- .
DATE COMPLIANCE ISSUED 2j -7?-- eT
F- _ _" `
1
. , � _ '
��
�:
-_.�,
`"
� �.
�__�
No...........�`�1 t.� 'a F�s..a:s�...........
THE COMMONWEALTH OF MASSACHUSETTS
T BOAR® OF HEALTH
_1.0..w... J. ...... .........OF......
Appliration for Disposal Works Toustrur#iun rrWtt
Application is hereby made for a Permit to Construct (:X) or Repair ( ) an Individual Sewage Disposal
System at:
�� C y��n/�
.. d.........Y.:. a? .... 5`.1...6.25...... ....................................... ...__......_.........
Location-Addresg or Lot No.
•-----.aka"d.A-4 :�.� .C.h i S�/_Jk.�.l�_ 'P�t4��! •r _..�. ?. ..__lY
Owner Addre s
W �.
.......... mil✓ ... �i:M. ._f........................ ... �_ �-�' -S.�.. W. s.�...ezrM he. VA..
Installer Address
Type of Building Size Lot....54yoo.?--•Sq. feet
Dwelling—No. of Bedrooms................-J______........._.......Expansion Attic ( ) Garbage Grinder ( )
aa, Other—Type of Building ..................:......... No. of persons............................ Showers ( ) — Cafeteria ( )
Pa Other fixtures
- -----------------------•-----------------------------------------------------------i---------• ••------------------
WDesign Flow...................—55.................gallons per person pert day. Total daily flow................ Q..................gallons.
WSeptic Tank—Liquid capacity6 _gallons Length___-_Ct....... Width.....G-_______ Diameter................ Depth................
x Disposal Trench—No..................... Width....e.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No.--_--__I_.__.____.. Diameter........d....... Depth below inlet......&.......... Total leaching area._..ZW...sq. ft.
Z Other Distribution box ( V-f Dosing tank ( )
Percolation Test Results Performed by................................ _ Date............................
Test Pit No. I......Im....minutesperinch Depth of Test Pit-------114.o_.___ Depth to ground water_______________- ------
rZ4 Test Pit No. 2........ ...minutes per inch Depth of Test Pit........M ...... Depth to ground water........................
_ ll�
O Description of Soil \ +�5�' — - ....... .4 1>
` S
x
W
................................................-----••-----•••----•••-•-•-------•••-•--••---_-••••---••----••-•--•...--•-•----•••--•------••...•••---...............................................
U Nature of Repairs or Alterations—Answer when applicable...............................................................................................
-----------------------------------------•---_.....
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITI11 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
Application Approved By..... .. ..... ....... .... .. - /at
te S-
------------ --- -----------------
Date
Application Disapproved for the following reasons:......................................... ............................................................
...............•-----•---------------......--------------•-•-----•-------.........--------....------•----•-•---•---••-•----••-•-•----••=-•-••---•--------•-•••-•---•---•-•--.......----••--••--•--•----
Date
PermitNo.......................................................- Issued•.' -_.�'�..
` ---------•--------------------
�D"ate
I'do......................... , 3. F:E$..............................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......................O F......................................------............................................
Appliration for Diipoaal Works Tontrnrtion Vernfif
Application is hereby made for a Permit to Construct V) or Repair ( ) an Individual Sewage Disposal
System at:
Address L cation- or Lot o. ••••••••
.fA �_ art-. h,!. Ti�v�=/3:..��Ptfl���... ., .. '7.._._._I!?e .S_.Z"..... rY,C'or
Owner Address
a -u Y• +�� �0 9 .._..... ............ .......-•--•-
I4istaller Address
Type of Building Size Lot.... OD...Sq. feet
U Dwelling—No. of Bedrooms................_'`3.......................Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building No. of persons............................ Showers — Cafeteria
A4 Other fixture
-................................................................................................................
W Design Flow....... ......... ....................gallons per person per,day. Total daily flow_.___........__._0Q.................gallons.
WSeptic Tank -�LAuid capacity�___...gallons Length...._C....._.. Width.....5....... Diameter________________ Depth_.............
x Disposal Trench— o..................... Width_...9.............. Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No______ ____________ Diameter........ ?........ Depth below inlet......4.......... Total leaching area..._-._.0.0..sq. ft.
Z Other Distribution box (4 Dosing tank ( )
Percolation Test Results Performed by.................................................... .... Date..........................._............
Test Pit No. 1...... ....minutes per inch *Depth of Test Pit....... _.....
Depth to ground water........................
( Test Pit No. 2..........:.....minutes per inch Depth of Test Pit........M........ Depth to ground water........................
Q+' Q grt t ------------------•--;---t•---....'-•----•-----.........._-------•--•--•e--------_----
0 Description of Soil....... --J...----- A�........En. ---•---��'� aC........--•-- --- -�-. -----t�G7�i+'�.Catx �A�'=�---------
x
M -•-----------------------------•-•----------------------------------------
----------
-------
•--------------------------
•-----------------------------------
--------------------------------
•------------------------------
---•-•----------------------•------------------------....•-----------------...--•--------------•------•--•---•----------------•-------•----------------------•-•-------------•--•-------------------•-
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 TITI.i� 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
.ned..... -`=•-- - ------- �.. .:-�7.1 '_� _t, ... ................. ...... •---••-
6' lf/ .r �✓/��il/L�J � ate
ApplicationApproved By..........................--- -----•-•----. - ----..`� --------------•---•----•-- -------• 7 ` 7 --•---
Date
Application Disapproved for the following reasons:------•-------•-----•---•--------••-•-•-•------------------------------------------------------•----------•-----
-•-----••--•••...-------•..............•...-----....-----•-•--....--•---------•----....___..........---•-...------...---------•-------•-----••---------------------------•------•------•••----•---------
4 ,c Date
Permit No.........................................................
"" Issued----- dof
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALT� .
r
...............................OF......... ...�'`'�..................................:...........................
(Intifiratr of Tomplianrr
SI-WS TOY lit the Individual Sewage Disposal System constructed (�or Repaired ( )
b -'..__.... ........................... ..... _..: --•-------------------
/� /
y j! Gf/ // (✓� .e. �6/ jLS stalleC� J
�j l:� C
has been installed in accordance with the provisions of r �15 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No....................Z................ dated__'_//- z-_]��-
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE........... ........................................... Inspector ... .. _..._..-----------------•-------------•-•--•---------•--......--•-
THE COMMONWEALTH OF MASSACHUSETTS
BOARD ?F HEAL . H
v - �.L '...................OF...... . ... '� .(/� -c�-
No........�5............ _ FE;u........................
�i��o��'1 ork,� , on�tr�rtuan rrntit
Permissio is hereby
granted
c.... P . _
to Construct or Repait an In ial' - eva .e Disposal po�s�v�lS}stem
�/ ¢ _�
l� � ..................................---••----•------•-••--•-•---.�... -•--f-�j at No. " Street as shown on the application for Disposal Works Construction- rmit NoC fi Dated 'O(......................
f •----- ••-------------------•-•-----
z 7 }t�jj ---.-----•----- Board of Health
DATE-----%-----_...--`---------- -------•-•----------------•-----
FORM 1255 HOBBS & WARREN, INC., PUBLISHERS ."'
�----- -r o ,L
Stt.,��L� �onntL.�i< =' �. �31✓Dtzaa.vC c
T'Zd l L 4 1~L.OV-/ s t I b - S = SSCU G.F.V.
33o v lSG % _ 4-9 rj 6.P o.
use t Epo0 GAL..
.-r)ISPos AL PIT - uSE l o0o GA.L.
t LV/S L L AOF--A = l5C> S.97.
1��o SF 2.S = S-7S G.P.D.
$cJ1TO�vl �2�A= 9E;O ST-.
TOTAL
ToTQ L t�d t L�f F Caw - 330 6.PD.
�f1GDLQT10tJ Z&TE t IQ SmIIJ, o2 L--SS.
fiiaST
it 4' • KT iw GAL. gl,r7
S✓3 �oXSEPTICr==:-
V. TQ�IK
SOIL. I o0o SR,v ;uv, IM/
GAL. iID D qe�2
LsAr-W
PIT
�t.6/t1•1 W IT4.1 A`.
Ja hI D WAS4IED
STo�.IE P .O
=1
C.C-.IZTtFtEtD VLC>-r
' L-
IaC.ATIo�, '���lt' �2t3�,sAgL�
G t V T 11=,{ T l-1 A T' T 14 lr p u .l.I��, 5lao�v ti.f ._A tJ R 1~ c�:c►.i GC-_
v4Z.l?( ni-i 60&t PLyG 4l/ t'( 4 TI--Iz: 51 Dr.1._I WC--
AtJb >E"('t3hCiC V7C-QUlC6MC-uTS D 'i'►�l~ ,�
r,
PATE .a d �� , ►J �....
B A.)(TCtZ,
05TEVc'_V1L_LG A5,1i,
tiJy('?J!✓lL�t.t i �U���/i `t' G Tlit vF�� C-�r mil{GWL� AP L-i
i•`t�C �:t-- U11-4UC-) 2, ter 1•G Lh(t W �o"C l_t I.c� _
x
• �sg .
•.,,� tA�.lk
U ayR
4f
t
I?
S
IZL
OW t-i�R ; Tom' ,S�R:�►C.�t,�
LOT 2d 00
S�A(,� �,� �� 4/4AS
?o ktr-)