Loading...
HomeMy WebLinkAbout0040 LOTHROP'S LANE - Health 40 Lothrop's Lane W. Barnstable P A 109 005009 t Mo i No. 4210 1/3 BLU Po- n(of m 9 0 GH 10001 Page: 1 CERTIFICATE OF ANALYSIS Barnstable County Health Laboratory y�'T�CHv`1� Report Prepared For: Report Dated. 3/31/2004 Cj 1%N Order Num r: G042O George Reinhart 40 Lothrop's Lane - West Barnstable, MA 02668' Laboratory ID#: 0424596-01 Descrintion: Water-Drinking Water i Sample#: 24596 Samuline Location: 40 Lothrup's Ln West Barnstable MA Collected 3/29/2004 Collected by: G Reihnart Received: 3/29/2004 GL Routine 4 A AL Oot ITEM RESULT UNITS 11 MCL Method# Tested LAB: IC Lab J Nitrates 2.2 mg/L 0.1 10 EPA 300.0 3/29/2004 LAB: Metals Copper 0.1 • mg/L, 0.1 1.3 SM 311113 3/31/2004 Iron <0.1 mg/L 0.1 0.3 SM3111B 3/31/2004 Sodium 20 mg/L 1.0 20 SM 3111B 3/31/2004 LAB: Microbiology Total Coliform Absent P/A 0 Absent 307 3/29/2004 LAB: Physical Chemistry Conductance 290 umohs/cm 1 EPA 120.1 3/29/2004 pH 6.7 pH-units 0 EPA 150.1 3/29/2004 P Note: Sodium level above the average.Those on low sodium diet may wish to contact physician. Approved By: o Cs� ( ,ab irector) _ Superior Court House,'PO. Box 427, Barnstable, MA 02630 Ph: 508-375-6605 Page: 1 E CERTIFICATE OF ANALYSIS Barnstable County Health Laboratory Report Prepared For: Report Dated: 04/28/2000 Order Number: G0005696 Stacy Reinhart 40 Lothrop Lane West Barnstable, MA 02668 Laboratory ID#: 0005696-01 Description: Water-Drinldng Water Sample ih 05696 Sampling Location: 40 Lothrop Lane, West Barnstable Collected: 04/24/2000 Collected by: Stacy Reinhar Received: 04/24/2000 Routine ITEM RESULT UNITS MCL Method# Tested LAB: IC Lab Nitrates 2.3 -91L 10 EPA 300.0 04/25/2000 LAB:Metals Copper 0.2 mg/L 1.3 SM 3111B 04/25/2006 Iron <0.1- mg/L 0.3 SM 3111B 04/25/2000 Sodium 14 mg/L 20 SM 3111B 04/25/2000 LAB:Microbiology Total Coliform Absent P/A Absent P/A 04/24/2000 LAB: Physical Che»ushy Conductance 170 umohs/cm EPA 120.1 04/25/2000 pH 5.3 pH-units EPA 150.1 04/25/2000 Note: Water sample meets the recommended limits for drinking water of all above tested parameters. Approved By:��ti� ,�.cr� r_r A-)LZ (Lab Director) sj l* Superior Court House, PO.Box 427, Barnstable, MA 02630 Ph: 508-375-6605 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS C DEPARTMENT OF ENVIRONMENTAL PROTI-C;ThO — r �d ' 2 D DEC 2 2003 TOWN OF BARNSTABLE HEALTH DEPT. TITLE 5 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION MAP t Property Address: PARCEL 0 0 5 2� LOT Owner's Name: Owner's Address: U A Date of Inspection: �I Name of Inspector- ��Company NameMailing Address: K A14 Telephone Number: ' t­ J• G� CERTIFICATION STATEMENT I certify that I have personally'inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection:The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: VPasses Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Notes and Comments f n ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will.perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page I s Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A .CERTIFICATION (continued) Property Address: all Owner. Date of Inspecti n: �/ O j 3 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. stem Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the. for the following statements. If"not determined"please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as'approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is.leveled or replaced ND explain: ; The system required pumping more than'4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health):. _ broken pipe(s)are replaced obstruction is removed ND explain: 2 a Page 3 of I l OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: (� Owner: Date o rinspecti is C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. L System will pass unless Board of Health determines in accordance with 310 CMR15.303(1)(b)Thai the system is not functioning in a manner which.will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100.feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A-copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of 11 OFFICIAL.INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: yX&tj&0 C Owner: Ar� F Date of Inspecti A System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes Nd Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or / cesspool GJ Liquid depth in cesspool is less than 6"below invert or available volume is less than '/7.day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number / of times pumped V Any portion of the SAS, cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface / water supply. _ ✓ Any portion of a cesspool or privy is within a Zone 1 of a public well. _ Any portion of a cesspool or privy is within 50.feet of a private water supply well: Any portion of a cesspool or privy is less than 100 feet but..greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen.is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] A (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a'design flow of 10,000 gpd to.15,000 gpd• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no _ the system is within 400 feet of a surface drinking water supply _ the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim.Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered es to Section D above Y the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. 4 Page 5 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE'DISPOSAL SYSTEM INSPECTION FORM 5 .,.TART B':;. CHECKLIST Property Address: A/I Owner: Date of Inspectio : Check if the following have been done. You must indicate"yes or."no"as to each of the following: Yes No Pumping.information was provided by the owner, occupant,or Board of Health Were.any of the system components pumped out in the previous two weeks? Has the system received normal flows in the previous two week period? c/ Have large.volumes of water been introduced to the system recently or as part of this inspection? t/ Were as built plans of the system obtained and examined?(If they were not available note as N/A) Was the facility or dwelling inspected for.signs of sewage back up? (/_ Was the site inspected for signs of break out? Were all system components, excluding the.SAS, located on site? ( ' Were the septic tank manholes uncovered, opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction, dimensions,depth of..liquid,deptli.of sludge and depth of scum? Was.the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: Yes o Existing information. For example,a plan.at the Board of Health. Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)] 5 Page 6 of 11 OFFICIAL INSPECTION;FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE`DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: Owner. Date o Inspection:— / FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): . DESIGN flow based on 310 CMR 15.203 (for example: I W gpd x#of bedrooms): Number of current residents: Does residence.have.a garbage grinder(yes or no): Is laundry on a separate sewage system (yes or it[if yes separate inspection required] Laundry system inspected(yes or no): Seasonal use: (yes or no) Water meter readings, if available(last 2 years usage(gpd)): Ud�%�l G✓Gj i� Sump pump(yes or no): y r Last date of occupancy, COMMERCIAL/INDUSTRIAOtt" Type of establishment: Design flow(based on 310 CMR.15.203): - gpd Basis of design flow(seatsipersons/sgft,eic.): . .. Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no):_ Non-sanitary waste discharged to the Tittle 5-system(yes or no):_ Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: CP 9� �ay Was system pumped as part of the i spection.(yes or no : If yes, volume pumped: gallons--How was quantity pumped determined? Reason'forpumping: . TYPE OF SYSTEM __�_Xeptic tank, distribution box,soil absorption system _Single cesspool _Overflow cesspool Privy —Shared system(yes or no)(if yes,attach previous inspection records, if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank _Attach a copyof the DEP.approval _Other(describe): Apmoximate age of all comRonents, date installed(if known)and source of information-. 14 Were.sewage odors'detected when arriving.at the site(yes or.no): 6 Page 7 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: 0,3 BUILDING SEWER(locate on site plant/%& Depth below grade: Materials of construction:_cast iron _40 PVC_other(explain): Distance from private water supply well or suction line:' Comments(on condition of joints,venting, evidence of leakage, etc.): SEPTIC TANK: ✓(locate on site plan) Depth below grade: 5 / Material of construction: /concrete_metal_fiberglass_polyethylene —other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions:J� p` k�✓� Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: 17, How were dimensions determined: Uz�a zopy�l �e 7 A� Comments(on pumping recommeddationsf inlet and outlet tee or baffle condition,structural integrity, li uid levels elated to outlet tlet invert, e, i ence of leakage, etc.): ✓/ GREASE TRAP (locate on.site plan) Depth below grade:_ Material of construction:_concrete_metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc.): 7 Page 8 of 1 l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY,ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM,INSPECTION FORM PART C C S SYSTEM INFORMATION(continued) Property Address: JI-P Owner: Date of nspectio . TIGHT or HOLDING TANK, y(tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches, etc.): DISTRIBUTION BOX: (if present must be opened)(locate.oli site.plan) Depth of liquid level above outlet invert:1 :Lt1��� Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover,,any evidence of kage into or out of box, et PUMP CHAMBEERI,&(locate on site plan) Pumps in working order(yes qr no): Alarms in working order(yes or no): Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): 8 } Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: ��� Owner:V6.,OH,4./ Date of nspection: SOIL ABSORPTION SYSTEM (SAS):_,Alocate on site plan,excavation not required) If SAS not located explain: why: Type leaching,pits, number: leaching chambers, number: leaching galleries, number: leaching trenches, number, length: leaching fields,number, dimensions: overflow cesspool, number: innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level ofponding: damp soil; condition of vegetation, etc. i ^ ,� 2 CESSPOOL4 �(cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil, signs of hydraulic failure,_level of ponding, condition.of vegetation,etc.): PRI L/""j7'(locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.): 9 . r Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 7VALVAlij,94 S / n / Owner: Date of nspeetio SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the u'p b ildin . PP Y g 6V t 1 i r 0 , a o ,U' 'PAY µ a . 10 Page I 1 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 0� l� Owner c� Date of Iiispecti n: SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 3 feet Please indicate(check)all _nethods used to determine the high ground water elevation: Obtained from system design plans on record-If checked, date of design plan reviewed: Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators, installers-(attach documentation) Accessed USGS database=explain: You must describe how ycu established the high ground water elevationti : - �� 1 i � / d� rsr 11 Permit Number: .__Date: Completed by: HIGH GROUND-WATER LEVEL COMPUTATION Site Location:_ !,�q ��ys I�l /✓l/ , �1� 'r��Q' �' Lot No. :Owner. ® e/U_� .4ddress: Contractor: c�iT r ^c-dress: ✓ �dlr,�G�% S Notes STEP 1 Measure depth to water table to nearest 1✓10 it. ...................... -� :................................................._:_.: .Date 11 !Il>3 mon-th/day/year STEP 2 Using Water-Level Range Zone and,lndex Well'Map locate site and determine: Appropriate index well........ ................... 7, OWater-level range zone ......... . STEP 3 Using monthly report "Current Water Resources Conditions" I I I � determine current depth to i w.aier I=vel.`or index well .......::......: /��' S�i . month/Year ' STEP ^• Using .Table of Water-level ,�`,dlustments � I for index well (STEP 2A), cun:ent depth I to water level for index.well (STEP 3), -and water-level,zone (STEP 2B) determine water-level adjustment•............................ STEP . -Estimate depth to high'v/ater by subtracting the water- level adiustrrient (STEP 4) from:'measured'depth to water level at site (STEP 1)............. .. Figure n 13 -R - ole c Oiilp�t..tl0fl TOiril. i ,.� ,f�:.� ��N .f:�•��t'1���' k> ,'�' �'...`..Y ..-........-..-`._.,_. � Imo_. :.=:�" ,,.... =i�i' _v...,.:..�........,...._ �(:fl�«�;�;puf) ...!�®� Rig` � f�:�r1��� ...,I � �—f®�� '��•. �/� i P 12 1 'BORTOLOTTI CONSTRUCTION,INC. 765 WAKEBY ROAD,MARSTONS MILLS,MA 02648 '� De 'TfCelkl 'O 508 771-9399 508-428-8926 FAX: 508-428-9399 tr 2 3 ? SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM T�yF°TH yysrq 19'9 PART A �� afPT elt CERTIFICATION c:+f Property Address: d L 9 Date of Inspection: 7 Inspect 's Name: er's Name and Address: VC _CERTIFICATION STATEMENT! I certify that I have personally inspected the sewage disposal system at this address and that the informa- tion reported below is true,accurate and complete as of the time of inspection.The inspection was per- formed based on my training and experience in the proper function and maintenance of on-site sewage disposal stems. The System: Passes Conditionally Passes Needs Further E do a Local Aproving Authority Fails Inspector's Signature: Date: /�/4zp 7 The System Inspector shall submit a copy of this inspection report to the Approving authority within thir- ty(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. INSPECTION SUMMARYe A)SYSTE PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B)SYSTEM CONDITIONALLY PASSES; One or more system components need to be replaced or repaired. The system,upon comple- tion of the replacement or repair,passes inspection. Indicate yes,nor,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,cracked,structurally unsound, shows substantial infiltration or exfiltration,or tank failure is imminent. The system will pass inspection if the existing sep- tic tank is replaced with a conforming septic tank as approved by The Board of Health. Sewage backkup 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): - 1 - r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Broken pipe(s)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 _< F 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 THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 Feet of a surface water Cesspool or privy is within 50 Feet of a bordering vegetated wetland or a salt marsh. 2)SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER,IF APPROPRIATE)DETERMINES THAT THE SYSTEM IS FUNCTION- ING IN A MANNER THAT PROTECT THE PUBLIC-HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is.within 100 Feet to a surface water supply or tributary to a surface water,supply. The system has aseptic tank and soil absorption system and is with a Zone I of a public ` water supply well. The system has a septic tank and soil absorption system and is within 50 Feet of a private water supply well. The system has a septic tank and soil absorption system and is less than 100 Feet but 50 Feet or more from a private water supply well,unless a well water analysis for coliform '1 organic compounds indicates that the well is free from pollution from bacteria and volatile o g po . n of am monia nitro en and nitrate nitrogen is equal to or less presence the facility and the p g ._ ,_ , than 5 ppm. D)SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backu P sewage a into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of efluent 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 clog- ged SAS or cesspool. _ Liquid depth in cesspool is less than 6"below invert or,available volume is less than`f/2 day flow. a , Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped 2- k SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) 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 SYSTEM FAILS: The following criteria apply to a large system in addition to the criteria above: The design flow of a system is 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: The system is within 400 Feet of a surface drinking water supply 'The sysfem'is within 200 Feet d` tributary toga surface drinking water supply " The system is located in a nitrogen sensitive area Interim Wellhead Protection Area ' IWPA or a ma d Zone Il of a public water supply Well.,, ( ) ' PPe P PP Y The owner or operator of any such system,shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Check if the following have been done: V Pumping information was requested of the owner,occupant, and Board of Health. ' None of the system components have been pumped for atleast 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. t/The facility or dwelling was inspected for signs of sewage back-up. ^ ✓,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 site. � The septic tank manholes were uncovered,opened,and the interior of the septic rank was in- `' / "spected1di'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 or approximated by non-intrusive methods. -3- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST(continued) The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Subsurface Disposal System SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM _..PART C SYSTEM INFORMATION FLOW CONDITIONS RESIDENTIAL: // Design Flow: d _gallons Number of Bedrooms: Nui r of Current Residents: (a Garbage Grinder: Q Laundry Connected To System:�� Seasonal Use,�� Water Meter Readings,if available- Last Date of Occupancy: — COMMERCLALIINDLISTRiAi:A) Type of Establishment: Design Flow: allons/day Grease Trap Present: (yes or,no) y , Industrial Waste Holding Tank.Present: Non-Sanitary Waste Discharged To The Title V System: Water Meter Readings,If Available: Last Date of Occupancy:- - OTHER: Describe) Last Date of Occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information:01w System Pumped as part of inspection: If yes,volume pumped: gallons Reason for pumping: TYPE OF SYSTEM: _j,!f'!§eptic Tank/Distribution Box/Soil Absorption System Single Cesspool Overflow Cesspool Privy Shared System(If yes,attach previous inspection records, if any) Other(explain): PROXIMATE AGE of all components,d to installed(if known)and source,of information:- Sewage odors detected when arriving at the site: Y . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C GENERAL INFORMATION (continued) SEPTIC TANK: Depth below grade: •• Material of Construction: concrete metal FRP_Other (explain) Dimisions:/0,!5-'.Y (e 'A- SS' Sludge Depth: Scum Thickness: Distance from top of sludge to bottom of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid p1lelin ation to o tlet invertctural integrity,evi nce of leakage,etc.) vsvc ,ic, IVA GREASE TRAP:_ Depth Below Grade: Material of Construction:_concrete_metal_FRP_Other (explain) Dimensions: Scum Thickness: Distance from top of scum to top of outlet tee or baffle: Comments: (recommendation for pumping,condition of inlet and,outlet tees or baffles,depth of liquid level in relation to outlet invert;structural mteg'ritjy'eviderice of leakage;etc:) TIGHT OR HOLDING TANK:AjO Depth Below Grade: Material of Construction:_concrete_metal_FRP_Other(explain) Dimensions: Capacity: gallons Design Flow: gallonstday Alarm Level: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) DISTRIBUTION BOX: Depth of liquid level above outlet invert: Comments: (note if 1 1 and istribution is equal,evident f solids carryover,evidence of leaka a into or out of box,etc.) N PUMP,CHAMBER: � ' .7 .... . . -Pump is in working order:._. . .._ r Comments: (note condition of pump chamber,.condition of pumps and appurtenances,etc.) -5- i. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) SOIL ABSORPTION SYSTEM(SAS): L,� (Locate on site plan, if possible;excavation not required, but may be approximated by non-intrusive methods) If not determined to be present,explain: Type: Leaching pits, number: 1 Leaching chambers, number: Leaching galleries,number: Leaching trenches, number,length: Leaching fields,number,dimensions: Overflow cesspool, number: Comme ts: (note condition of oil,signs of h draulic failure level of po ding,condition of vegetation, etc.) CESSPOOLS: Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of Cesspool: Materials of construction: Indication of groundwater: Inflow(cesspool must be pumped as,part of inspection) Comments: (note condition of soilk, signs of hydraulic failure, level of ponding,condition of vegetation, etc.) PRIVY::(J Materials of construction: Dimensions: Depth of Solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.) 't ..t• .r•." ,. .,.. •t t SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) SKETCH OF SEWAGE DISPOSAL SYSTEM: Include ties to adeast two permanent references, landmarks or benchmarks. Locate all wells within 100 Feet. O DEPTH TO GROUNDWATER: , Depth to groundwater: yL , Feet Meth of Determination or Approximation: ,�O,��Xi -7- Y TOWN OF BARNSTABLE LOCATION �,C,-E-_ oO E WAGE # SG /I VILLAGE ASSESSOR'S MAP & LOT /Oq - 001=oo INSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITY /.)'U o _ LEACHING FACILITY:(type) J) *S (size) - =/ NO. OF BEDROOMS_ IYATE WELL PUBLIC WATER M BUILDER OR OWNER c,\ DATE PERMIT ISSUED: 3 / S 0 DATE COMPLIANCE ISSUED: ZZIZf E 0 VARIANCE GRANTED: Yes No O" /� i 1 ��- ��� j/��GK�•� �Uvs-e No'? THE COMMONWEALTH OF MASSACHUSETTS n BOA R� F 0 Pf �.,4 ..........................OF............... . . ........ ............................ Appl rati.nn for Uhiposal Works nnstrurtion ramit �e�14 1y� �� Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal Sy aT_/., . '® r . ,�s......�,.�.�......... .......W:.. _ ,A.-- ----......------...................... ..... ........... 01 t o or Lot No. ...... .. / - o/` :. �s--------------------------------- -•--- ......... ..._..__._.....-------....._ - Owner ........Address W Installer Address Type of Building ze Lots�.��...-...-..Sq. feet Dwelling—No. of Bedrooms___ . _ ..........................Expansion Attic ( Garbage Grinder (A/2)_... 'k Other—T e of Building n......... No. of persons....................... Showers — Cafeteria Other fia u ----- -- -- -- .- WW Design Flow............ ........................gallons per personyer ay. Total daily flow......�!�4...._._..........._._.___ lons. W ,/ Septic Tank—Liquid capacity.? allons Length- C�... Width_... a... Diameter................ Depth_..•..... x v Disposal Trench—No............ ....... Width.................... Total Length_._; .... Total leaching area........._._.._ __sq. ft. Seepage Pit No....: ._.... iameter../P.......... Depth below inlet._....r............. Total leaching areas3.7l -sq. ft. z Other Distribution box (1/) Dosing tank ( ) W Percolation Test Results Performed by..... ��..................................................... Date..�_. ....f........ a Test Pit No. 1...... ..._minutes per inch Depth of Test Pit./.l ...... Depth to ground water........ ......... 44 Test Pit No. 2...............minutes per inch Depth of Test Pit.................... Depth to ground water......._................ 9 ...._._.-••-•-•-•••-•-•-•-••.............................................•.......................---......................................................... ODescription of Soil........................................................................................................................................................................ x V ......................•-••-------.._.------•----•-•-••--•••-•---............--•---•--•----........_••--------•-------.....--••••------...-•--•-•-•_.....--•--------------...--•-•••-----..._.._----...... W UNature of Repairs or Alterations—Answer when applicable............................._.._._..............•.•............................................ ..-••••••-•••••••••••••--•---•••----•----._.-•--•-•.......................•-•--------•-••-------••---•---••.._....••••--•••-•••••--.........----••••••••••••--•-•-••-•-•••-•------•---•-•-•----••-...... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health.. Signed ! k ......_!t4.!_ .. �!Y`� �. ••.`. .. ...... Application Approved BY ---•-----. .. ...��.._. .. ------ / a� Date Application Disapproved for the following reasons:.......................... --•----•----•-••-----••----•--....--•--•---•----..._---•------••--•-....-•--------- ----•-----•---•--------------•-•--••-----_........--••••••--•-----.....-----•••--•----...__._....._...._........._-•••-...........--•••••-•-•---------...•••-•--••---•-...••-•-•-•-•-•-......•••----•--- Date Permit No...... ..` :L.. _'' Issued_.__._ ���..-•••-------- --•- ---------- Date FEB THE COMMONWEALTH OF MASSACHUSETTS BOARD JOF H Appliratiun for Disposal Works Tonstrurtiun Errant Application is hereby made for a Permit to Construct ( 7or Repair ( ) an Individual Sewage Disposal Systgn at: 9,16 1..�T 1e -•...•..........•................ ........•-------..........................or Lot No. ..._.. ---.........»... Owner Address W Installer Address . Type of Building Size Lot._"_ 'a .....Sq. feet U Dwelling—No. of Bedrooms.__ ___ ?................. Expansion Attic ( Garbage Grinder ( •"------ 04 Other—Type of Building __ :_ _........• No. of persons............................ Showers ( ) — Cafeteria ( ) 04 Other fixtur s .....;...................._..................................................................................... W Design Flow•.........-.Q .......................gallons per person per/day. Total daily flow.....: -fOz9........................gallons. WSeptic Tank—Liquid'capacity.0 ; allons Length. .x..... Width__. _,�.�_... Diameter................ Depth._,-'._'.......... x Disposal Trench—No.................... Width.................... Total Length..--._-----_... Total leaching area.............. _.sq. ft. Seepage Pit No. iameter..l .......... Depth below inlet__- ___ Total leaching area. .; rsq. ft. Other Distribution box ( Dosing tank ( ) `" Percolation Test Results Performed by %': 'p ���....� ..................•_._......_.. Date... "..=-` .._.._..._.. a Test Pit No. 1....�......minutes per inch Depth of Test PitZ.�...... Depth to ground water..__...��........_.. (s, Test Pit No. 2.................ninutes per inch Depth of Test Pit.................... Depth to ground water........................ a •-•••---...-----••--•---•-•--"--"--•-•--""-•-•--•--•---""•"...-------"-"-'"-•"""-•"•-----'--'-------......................................................... .0 Description of Soil........................................................................................................................................................................ x U W ------------------------------------•-----------•-------------------•-----------------...-•--------"----------•----------------------•--•---•--------........--------•-•----•--"-"•"-"•--•"......-"- V Nature of Repairs or Alterations—Answer when applicable............................................................................................... ...---•-----•-----......"•---------------------------•--•.......-•--•---•-------•-------------------..........------------------•----------•-•---------•------------------------------------------..--- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed...................................................................................... .......................... %✓C�,�[ 2� Date Application Approved By.. r .� - ab ...... Application Disapproved for the following reasons:-•-•-".................................•---............----------------..._.._._._......_._...____......_.... ......................................................--•---"•----------...----------------••-•--•------ •-•---•-••-•-"-""._....... Date Permit No. r /'/ ----------------» Issued. �""'�' - » THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .. ! ....................0F..� t t �. � .................................... Trr#if iratr of Tuniplianrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( or Repaired ( ) � �:................ r Installers• f has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No �j__++�:.'..N __._____ dated---- - ___._ rt.._ ... THE ISSUANCE OF THIS CERTIFICATE SHALLAOT BE COidSTRUED AS A O AR TEE TH i4THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................ Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH No....•�:P....�.��t. .... � FEE.. . «J Disposal Works Twuns#rnr#iun rrutit '. Permission is hereby granted_._j/ :.C._.._._, . to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at No..L�fi`y � � ........... f�� t� �"G' Cit ��st�en , ' ram{•�� —Q as shown on the application for Disposal Works Construction Permit No Dated...... _ .%�i.1=/LA.C. __'__••'1_...�._�.......___ Board o -Iealt� DATE........S' FORM 1255 A. M. SULKIN, INC., BOSTON SE Prl c SYSTEM PRORLE f.4"Q VARIES f\ "' r i ""i 0} t •.• n w'AK K iliVN _ Iu/A. 1 f .►:b f/A//SNGRA04 Ni!!vqW WAVR f0°I .•/'°I 1� YA', , I t ti 1` .p� •�•��. � r 1; ly9rfNIO/S warOVE- � o _. • n . / � ,,up o 0o p �.�• c�uapo0 ,oisr/eiQ�TrON n o oa a Op o 0 p e D ROX �oOGo Cobb e +r �o t Lam__ GALLUA' /'.•L:a., i rxuJNfo ^Jdc ��00 " 3.S o Oogo°2 d-/Q .f6.'.4'fORCr»" ` lyJ., .. JJt�at ��;� c .' v �0c60 . . Q,t3ENEN' , AG•. c o i• ' /AYCIJ7 lfNA'Rt/r °JOOIJ F WA. < r t � • — 10 O,•!"� Ni p.ttiNfGYtLiO (r(y�l�° .. .^ j0' oho00p 40:e Vopo ''� 46 SEPT/C TANK" c�;o t Q ��00 e zEAC*lw P/r ♦ rvnefllresalcaNJ. y;`. . �x: .+ r CAAeAOtasswst_ NO- . . InrwL esnNwrwo uew 410 iPa . - fa I!2, 1 ,Lelt°lnriav wArE• •I '.wrN/l+Baf.. , 71\ [,.+.. A7//VeER of tcArnfs r►,r a , J/otVAl4wR6r•tIRfJ ', \ I r 109 v• 2.04mtr 219 4" ABSERVAT/O/V P/rS. °oa ar�.�ee ,- 6e.6ao,'' , •}' wre 10/21/66 L,O,1 5{ LOT 13 P!R!(wNEO by O•r!s t.✓s .. :•,psA[LEAcv�a6 /feevrov. /S6Ao i .- G � .' ,v. � -NOTES• .. .' 'I I ., •� ai � 1,b:tr fly t''d.t + ' r', 'y 'a '`\ ♦ /• fLEVAr/°N,7 ARE 6AJE0 ON RySdnrO _'aft": '� �� • � - t� /AO OM lrlN a <.rNt Nir/C JrJJtN JNALL.OE .A/J/ALLEG AQ'cNOANf 7O i .�, C•.l Y1 Y �', , ik} ''y�1 /Aur[oCAL RUGL] 7NAr APP4 ^ d• "' I a^ r+'ti �:�t3-. R v.AeR ro &qCx,-1jj1wq, rNc�ar>tfwrEaowxo e/,vMu�' '!f_.::Y RECEIVED . I .. JNAL[BE A/OT/fct0 + y/t i Aus p.2 MA� •� 'r�. .` \• r - I rwt Aloerw ARROW sNA[L A101 Of V.ff0 IroK I ti a. t.• ..o JO[AR A'VA'ICJES `• ,� •�.ti. o t . , .0 WArfe JV/PY IJ PANVIDIO .eY_►✓lfC_-..._ --.}.- ti 1. .OIO IU110'S NIGIIW�Y ....� _ ^ r.: ) 1 ..• f.,� d61w%/ y/L N.1 �AW r'J/S !''-7 �.. � A ` . .V •' 1 • .. C[ .vJ � A/�o A � NC �i N •CAW 7:i �irJ LOT 14 " �..�- � 'I ' •� !.sEl1 " .Afnwa y1�A1r1Y iuAl • � . �o . ,�. ,. ' d • :LOTHRO(3S LANE " P/,SAANSIAOLC MA '. , rh + 1. 00 �' ,• 1 FLOc;G f'LAI N ..c. _ .� UPPERCAPE ENG/AIEE %Mint .' �.• \55-20W t J/ ZONE. 30/15/15.. L�.i`1 IiEF .PLAN 41R1.SS.. 9/3"/�Tt .e/1 1P.O.Qd LIT swowj"NA LOTH HOP S♦ 40 PUBLIC RAM1 lfAtt` 1-30 _.__ SEPT/C SYSTEM PROF/LE +; A'/.VIJN GRID! OvfR ..5':''. A•U•' rP J=�-� - LlACM/NG v/r. . VARMS ' ► 6 n AvN Ar+CN WAER Poor ror.7►'-Y.". NGRAOE ;G �'.0 .,�• i IrwJNlOf>FwJrgyE- 000 L O ,0/STR/L�[/T/ON0,)0000 0 � •°uo�°� lJ L€�__ CatLUN r4 nL,A,r uwawfo Q 40 e 3 S p �O Rd UJ , 1 G7ti•'i'<!� d-/O .Cf:.tfORLG' [XUJNfO . L J/GNf j00'�OC Y °�Q60 n� /RicartavtRt/t fop e0 Q,tSlNlN.• �� • K,r °()O/�n7 N7'fO..fE+N/AtLl4 Y�o��°4 n n - n r -- .. j0• ....// .' (7eOU SEPT/C TANK e r 61e5 a . 6 GG- se— ',.. I DES/yN GR/TERIA f •V f ,•9 .•,, 7� ,vunele oy esoRaonJ:� ^r• %•+. �'•' •� r GwReAGe p.7roew�- NO. .. . Mrq,.lJr/Nwrso fLOW 410 CPA ' . .. - }!f-/1 ,I!R[OHri6V �fw-ri• •r •.M'•V�fw1CA.... • L:n. ' ^?Nell df ltaf+vr+i*13..a 71\ .YotluwL<•�Re�•l7RN• a• QBSL-R04r/0N P/TS eermnAusrL.• a�'• ,_ ;` LOT 13 LHrc 10/21/86 I f?RfILPNLD br O•rL.f f•✓t '•7VTw[ LfAfA'+A/6 AROVAOIa. yid f L0 15( o r MAW 0.•-Utl r T. q[Cis✓ rv. ca •' NOTES� '. � .• > : ' '� y +• 1°�� ~d i t \ � ' �. • �\ , /. ECEVRAONJ ARE L1A7 t0 ON 9ss✓w[•4..O+f#o/7 .�, � fk •-•� 4r � iae er/ri L r7+!JfArK JrJrrrr MALL aL+[arwLtEo wCYdPowNs 7a , a = <.i �' r4 + - ' nr[f 3' /ANrLOC.tc Ot"-J Writ wlfri.Y 7 df S• Tt I • ea.` - a f•R+eR ra AwCA'fiL[+Ny, Tnlstplp4Afeamp OA m*Aal' - + I pECEIVED 1 \. 1 JNau er Norii+moo AugQ7P 1989 'f I 7•'+L NORIn ARROW SNALL Np1 of UJfo A'OI! _ 1. �� �r• JOIAR IV.tMJLJ "J. V.IILRJVIPY:JRtNVIOro e✓:A!. ,t_-_ 0lDgNG'SHIGI�WAY .7 I ' , �, 7 , L.�! ✓t�wRu♦�vrf,��pt`frwr7L��,,tri[S Ary��'• •'.+ . .. i I C[lwr l'Qwv/4+COH/[ifNC�WirN Jieirfi7l 1 ...: / f3'AN'+�t SEPT/C AE3/fiN .r- �+ r • L e..s�e� ..wrrww:�xt�wrrrt.iweAl + ` �dTLOT 14J. 1ANE 1 �.•. ,° •9i ,1 . I t i.\, .. W r BAANSUsLe ►A r ♦ 1 1 1 F1000, PLAIN ..c.._ (/PP£RCAPE E�1/6/A11,0W fig. -ONE'V 30/15/15.. L�.�`i ItEF .RAN 41tl/.53.. yt3 RtE.sA RO.O,r l/7 LOTH,ROPS\ �"� e 1..' 40 PUBLIC 11RI stA[t� 1=30 L Department of EnvironmentalManagement/Division of Water Resources WATER WELL COMPLETION REPORT WELL L CATIO GEOGRAPHIC DESCRIPTION Addres D Rd _ S E W of f/��_(Jeer!` _/aMrclel City/Towne w1 n [t fric�wop 14UF l I► v " 'I (road! Well owne Address R r A( 2fl N Q E W of 0 {/M)/ M S s, (mi.In tenths) (clrrde) Board of Health permit: ryes no ❑ intersect. w IE�/gd`n WELL USE WELL DATA Domestic Public❑ Industrial ❑ Total well depth ft. Monitoring❑ Other Depth to bedrock AIM ft. Method drilled xy Water-bearing rock/lInconsolidated material: Date drilled h AM Description CASING ,r Water-bearing zones: Type q P2 1) From To Length IAII ft. Dia(1.D.) in.. 1 From To Length into bedrock ft. 3) From To Gravel pack well: dia. Protective well seal: Screen: dia. Grout-0 Other MUD Slott; , length�frorr/: 0 t PUMP TEST Static water I� below land surface lGG ft. Date �/� Drawdown-� ft. after pumping�hr. min.at Lgpm How measured ! Recovesy �ft. afterhr. min. 0 LOG of FORMATIONS COMMENTS Materials From To tin o ell M /D 340 Drill lY' q Q s Mass. egistration O Fir 1 i Address © QQ City/To n' ' %r Si nature of supervising registered well driller Please print firmly 64 BOARD OF HEALTH COPY t. �1{ittitiii(itiiittiitittttiif)ifittfiitiitttltfititlitltfitifiitlitff i(tfiti4►t1{ttitfiii;itifitt(tflitittf tflfifttt'iitftititt(({i(►ifttittifitf[tffit(t#(tiff ittt141ttttltittttitftlitfSlt►(tftftfiiiift(ttlititi(iiittttfl►itititltttitifif()/f� lENVRROT ECH LABORATORIES 449 Route 130 Sandwich, MA 02563 • (508) 888-6460 CLIENT: Jim Davis LOCATION: Same ADDRESS: Lpt 14 Barnstable. MA COLLECTED BY: _Larry Wile SAMPLE DATE: 3/2/90 TIME: F DATE RECEIVED: 3 2 90 SAMPLE ID: ET566 JOB #: WELL DEPTH: 120 RESULTS OF ANALYSIS: Parameter Units Recommended limit Result Coliform bacteria/100 ml (MF Method) 0 0 '~ e: pH pH units 6.0-8.5 6.61 -_ Conductance umhos/cm 500 91 =` Sodium .._. mg/L 20.0 .. 11.8 Nitrate-N mg/L 10.0 0.03 Iron mg/L 0.3 <0.05 RE Manganese mg/L 0.05 -3 i= <0.01 E Hardness mg/L as CaCO 500 3 7.6 Sulfate mg/L 250 ., 10.26 Z Potassium mg/L 20.0 0.3 Alkalinity mg/L 200 12.4 Chloride mg/L 250 15.6 Turbidity NTU 5.0 2.6 Color APC units 15.0 <1.0 Background bacteria COMMENT: Chlorinated hydrocarbons are typical of chlorinated water. Total not to exceed 100 UG/L EPA Method 502.2 See Attached,,' Chloroform 8.0 UG/L Bromodichloromethane 2.0 UG/L Dibromochloromethane 0.8 UG/L YES No WATER IS SUITABLE FOR DRINKING PURPOSES FOR PARAMETER TESTED. )RX ❑ c� DATE 3 �� ��tWlllllU!ltlltUlltlttutllittttlltlllllllillttltlll!!!lltUllUttlllttl!!!llffilittltli!!!t!tllUlUtiltiltlllilEfittilllllt!!lltltttlltit{tillll�tili !!!1lltlltiltUlllltliti!!!!t#!1!t!ltlllUtlt!lllUltt!!!!Illiltllllllit!!lltltl�� GROUNDWATER II ANALYTICAL EPA METHOD 502.2 Volatile Organics (GC/PID/ELCD) Sample Designation: ET566 Project Name/Number: Davis/ET566 Laboratory Number: 006515 Date Analyzed: 03-06-90 Sample Matrix: Water PARAMETER CONCENTRATION DETECTION LIMIT (ug/L) (ug/L) Dichlorodifluoromethane BDL 2 . 0 Chloromethane BDL 0. 5 Vinyl Chloride BDL 0.5 Bromomethane BDL 2 . 0 Chloroethane BDL 0. 5 Trichlorofluoromethane BDL 0. 5 1, 1-Dichloroethene BDL 0. 5 Methylene Chloride BDL 0. 5 trans-1, 2-Dichloroethene BDL 0. 5 1, 1-Dichloroethane BDL 0. 5 2 , 2-Dichloropropane BDL 0. 5 cis-1, 2-Dichloroethene . BDL 0. 5 Chloroform 8 0. 5 Bromochloromethane BDL 0. 5 1, 1, 1-Trichloroethane BDL 0. 5 1, 1-Dichloropropene BDL 0. 5 Carbon Tetrachloride BDL 0. 5 Benzene BDL 0. 5 1, 2^Dichloroethane BDL 0. 5 Trichloroethene BDL 0. 5 1, 2-Dichloropropane BDL 0. 5 Bromodichloromethane 2 0. 5 Dibromomethane BDL 3 . 0 cis-1, 3-Dichloropropene BDL 0. 5 Toluene BDL 0. 5 trans-1, 3-Dichloropropene BDL 0. 5 1, 1, 2-Trichloroethane BDL 0. 5 Tetrachloroethene BDL 0. 5 1, 3-Dichloropropane BDL 0. 5 Dibromochloromethane 0.8 0. 5 1, 2-Dibromoethane BDL 2 . 0 Chlorobenzene BDL 0. 5 Ethylbenzene BDL 0. 5 1, 1, 1, 2-Tetrachloroethane BDL 0. 5 m-Xylene BDL 0. 5 p-Xylene BDL 0. 5 o-Xylene BDL 0. 5 Styrene BDL 0. 5 Isopropyl benzene BDL 0. 5 Page 1 of 2 GROUNDWATER ANALYTICAL Sample Designation: ET566 006515 PARAMETER CONCENTRATION DETECTION LIMIT (ug/L) (ug/L) Bromoform BDL 2 . 0 1, 1, 2 ,2-Tetrachloroethane BDL 0. 5 1, 2, 3-Trichloropropane BDL 0. 5 n-Propylbenzene BDL 0. 5 Bromobenzene BDL 0. 5 1, 3, 5-Trimethylbenzene BDL 0. 5 2-Chlorotoluene BDL 0.5 4-Chlorotoluene BDL 0. 5 tert-Butylbenzene BDL 0. 5 1, 2 ,4-Trimethylbenzene BDL 0. 5 sec-Butylbenzene BDL 0. 5 p-Isopropyltoluene BDL 0. 5 1, 3-Dichlorobenzene BDL 0. 5 1, 4-Dichlorobenzene BDL 0. 5 n-Butylbenzene BDL 0. 5 1, 2-Dichlorobenzene BDL 0. 5 1, 2-Dibromo-3-Chloropropane BDL 3 . 0 1, 2 , 4-Trichlorobenzene BDL 0. 5 Hexachlorobutadiene BDL 0. 5 Naphthalene BDL 0. 5 1, 2 , 3-Trichlorobenzene BDL 0. 5 BDL = Below Detection Limit. "Trace" indicates probable presence below listed detection limit. Method Reference: Method 502.2 - volatile Organic Compounds in Water by Purge and Trap Capillary Column Gas Chromatography with Photoionization and Electrolytic Conductivity Detectors in Series, U.S. Environmental Protection Agency, EPA-600/4-88/039 (1988). Page 2 of 2 Y i No.-- -- --- Fee---- BOARD OF HEALTH TOWN OF BARNSTABLE ZippricatioriArVell Con5tructionpermit Application i5 hereby ad fora pepnit to Construct ( ), Alter ( ), or Repair (>)an individual Well at: ---------------------------------------- Location — Addres Assessors Ma and Parcel -=S - a r�� S )- P-- -=--- --- ----- -- ------ --- --- - - ---- Owner Address Installer — Driller Ad re Type of Building Dwelling-------------------------------------------------------------- Other - Type of Building No. of Persons---------------------------------------- Typeof Well—---------------------------------------------------------------------- Capacity------------------------------------------------------------------------------- Purpose of Well------—---- —---- — --— --- Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation — The undersigned further agrees not to place the well in operation until a Certificate of Compliance has been issued by the Board of Health. Y Signed ly ! — l] mot 1 _F_ date — Application Approved By--------- -- ----- - +.�------------ .e�_�1__= �_ —.. date Application Disapproved for the following reasons:----------------____—_________—----------------____—________--_______—______ ------------------------------------ date -- Permit No. -----------------------------—---------- - - Issued---------------------------------------------------------------------------- ------------ date BOARD OF HEALTH TOWN OF BARNSTABLE (Certificate Of Compliance THIS IS TO CERTIFY, That the Individual Well Constructed>:�; Altered ( ), or Repaired ( ) bY----------- ---------------------------------------------------—-------- —---- --- —W Installer 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. -----------------------Dated------------------------- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE --- —_____—- --- ------------ Inspector------------------ - — -—------------------ No.-- - ---- Fee ---- BOARD -------- BOARD OF HEALTH TOWN OF BARNSTABLE � Application-*rVell Co0tructionPermit Application is hereby made for a permit to Construct ( ), Alter ( ), or Repair ( /`)an individual Well at: lJ S Alt Location Address Assessors Map and Parcel I;cJ � s f �Qrra Address Assessors Owner Address -------- - l - — fir. _ �2 (� Installer — Driller' f Address Type of Building Dwelling-------------------------------------------------------------- Other - Type of Building ----------- No. of Persons------------------- Typeof Well----------------------------- ----------------------- Capacity ------Purpose of Well----------------------------------------------------------- Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation The undersigned further agrees not to place the well in operation until a Certificate /oof Compliance has been issued by the Board of Health. Signed / _ �a1 ?' tea^( _:=- ` -` �'�//ak" Application Approved By------- -- — `�`� �e'~'-{'== = - -- _ `— date Application Disapproved for the following reasons:------------------------------------------------ -------`--------- ------------ date PermitNo. --- ---— -— - - —----------------- Issued----------------_____ —-_ __------------ — date BOARD OF HEALTH TOWN OF BARNSTABLE Certif sate ®f (Compliance THIS IS TO CERTIFY, That the Individual Well Constructedt( C7, Altered ( ), or Repaired ( ) —---- -----------—---—-------—----—----—-------------=--------- ------------------------------ Installer 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. --------- ---Dated-------------- 1 THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE-----------— - - ----— —-- - - Inspector - BOARD OF HEALTH TOWN, OF BARNSTABLE Vern CongtructionPermit No.W- C/_ _------ Fee Permission is hereby granted --'------------- to Construct (a ), Alter ( or Repair ( ) an Individual Well at: No. - - ` =ra'CJ'? "i- -L'- -----------------( .------ --------- Street as shown on the application for a Well Construction Permit No.------------------------------------------------------------------------------------ Dated------------ - - _=�= t�'Y- ---- Board of Health DATE-------------—---------------------—---------------------------------------------- 6ERT/ C S Y.5 T�/4 PROFILE-. GkAGE JVEiC G 4,0 { 77 N� .Avc ae cry v/� N/ICJ pl rC S/yr PER F" r y Z � 5 3O i c fTT` a?1 uo 00 r1 BALES r � PkECA " C0�'JCkErF � � C)!J�D j V � f /G __ ` _ • . . H_- /p APE it'FORG'E: jn� 5G 54 52 ? 4e S,EPT/C TA/t/fC 46 44 , - 2 7 32 - r 5 A, ' GG Z EAChIIiV4 P/T Gs- ll!�e" -5Z4 TY 70- t \ \ 7� 4 N0 TOTAL E,T%rlar�o w 440 GPD. 1 (71/ D - NERCO CST,Oit/ it'�97E 9 i'/�✓�/�/G'� l? .0 yy.o ,�;UiyB C-• P Of LF/o%'�," i P/7� 2 � 16109 5F r 2.06Pa/SF 219 4Po F1 _- i \ -- 78 sf X,88 4,P,�r - GG.G 4oD 10/ 21/86 LC'T 15 `b I O ,�'ERfi'�R/'/EE G@, !1 �1 'i0�Ck1:/� '1fpyti�?tT.!+ : ?_ GG C? G4 �� ej 14ti'OTE—S P.PO w «ia}� APE OA�ED C N f-.Z aw eZ 474 7V17 D AC!'Q.PDING 7'0 - GO `• - 34 � ,,� ' . �_ ,. P.t=: ik TG' ,BACXf,'c:.C/,-vy, T.NE_,By,P,�ST/�/�l�;gQA�D 9F �E,vGT f/ SHALL 4 E A10r1F1E'D `� `• \ 1 y T.�lE /US'�i;i A ��?6t, s. A.:L NO> ZE U.S ELi FOk S k/ArER 5vP,�y ,S :c.eoVrvEG ,B y kA/F.�4 _ Alw'E•Yo� / cr~O`�iva�l•V o�E sc- \ 1 I \ 1 c LEA�v SAS '! �C/.9N�,E \ _ S/TE PLAN - \ 8. E�—r/L� JeGt�.6t �Cas..� C'ER C1/§STE,Q F �9�✓.. ._ � 3 ,a , _L0T 14 \ - . 5z s j � LO I H a�0�S l..l�N C i w , BA RN S i A 13L E MA c �p N - 2 55-2o W -J — ' ' �-`_ ' � U/AOR CAPE , A16IAIZ �RIA16 ' PLA N 418/ 55 _. RF 30/ 15/ 15 y/3 A Tz— . 6 A - ,:.)o 6 7 LOTH(=for, I'`�, o� S� , 40 PU131-IC RQW, . v Tom. 8 i7- 8� tK�IwN ety , i - 30