HomeMy WebLinkAbout0099 LOTHROP'S LANE - Health 99 Lothrop's Lane, West Barnstable
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BORTOLOTTI CONSTRUCTION,INC. �. of 0 ,�►
765 WAKEBY ROAD,MARSTONS MILLS,MA 0 (, y�[ryoFPTrgB�F
508-771-9399 508-428-8926 FAX: 508-428-9399`t
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION F
PART A
CERTIFICATION
Property Address: qq
Date of Inspection: 7 Inspector's Name:
PVF#er's Name and Ad ress: G
U,
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 tems. The System:
Passes
Conditionally Passes
Needs Further Eval tion By th Local Aproving Authority
Fails
Inspector's Signature: Date:
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 5UMMARY:
A)SYST PASSES:
0I 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 -
N
F
'.SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
f� CERTIFICATION (continued)
f
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 . . . ...... ........ w -._ _... .. -
Obstruction is removed
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 a septic 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
bacteria and volatile organic compounds indicates that the well is free from pollution from
the facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less
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 CUR 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.
Backup of sewage 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 outlet invert due to an overload
ribution box above ed or clog-
. . , .,•.d.. ,
ged SAS or cesspool. -
Liquid depth in cesspool is less than G: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
-2-
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 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 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:
_Pumping information was requested of the owner,occupant,and Board of Health.
4,,—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.
L""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.
��Y��/�l� he site was inspected for signs of breakout.
--4 j A-ll'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 tank was in-
spected'for condition of baffles or tees;material of construction,dimensions,depth of liquid,
Aepth 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-
. - `' �{.0 I 1. �.a ik�•:'r:i.Yk`:..
r
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
21
PART C'
SYSTEM INFORMATION
/ FLOW CONDITIONS
v ,
Design Flow: llons Number of Bedrooms: Z74 Num of Current Residents:
Garbage Grinder: Laundry Connected To System: Seasonal Use:
Water Meter Readings, if ilable:
Last Date of Occupancy:
COMMERCIAL/INDUSTRIAL:/J�
Type of Establishment
. _.
Design Flow: gallons/day. Grease Trap Present:.(yes or'no)"
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�ource,gf informat' n:
System Pumped as part of inspection:_�L If yes,volume pumped: ' gallons
Reason for pumping:
TYPE SYSTEM:
Septic Tank/Distribution Box/Soil Absorption System
Single Cesspool
Overflow Cesspool
Privy
Shared System(If yes,attach previous inspection records, if any)
Other(explain): _...
P OXIMATE AGE of all components,date installed,(if known)and source of information:
` 'Sewage odors detected whofarriving at the site:
-4-
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
GENERAL, INFORMATION (continued)
SEPTIC TANK: v �
Depth below grade: Material of Construction: concrete metal FRP_Other
(explain)
Dimisions: y.5,X,6r 5- Sludge Depth: . Scum Thickness: "
Distance from top of sludge to bottom of outlet tee or afne:
Distance from bottom cif scum to bottom of outlet tee or baffle: /d
Comments: (recommendation for pumping,condition of inlet and outlet tees orb es,depth of liquid
level in elation to utle ' ert,s ural integrity,evidence of leakage,etc.) A a 1,500
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 of baffles,depth"of liquid
level in relation to outlet invert,structural integrity,evidence of leakage,etc.)
TIGHT OR HOLDING TANK:
Depth Below Grade: Material of Construction:_concrete_metal_FRP_Other(explain)
Dimensions: Capacity: gallons Design Flow: gallons/day
Alarm Level: _
Comments: (condifon of inlet tee,condition of alarm aiid float switches,etc.)
DISTRIBUTION BOX:t/
Depth of liquid level above outlet invert:
Comments: (note if leyeland dist 'butio is equal,evident of solids carryover,evidence of l ge into
or out of box,etc.)
_. .-_PUMP CHAMBER
_._.Pump is in"wofluitg order:
Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.)
I
I -5-
SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
SOIL ABSORPTION SYSTEM(SAS):
(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:Leaching chambers, number: Leaching galleries,number:
Leaching trenches,number,length:
Leaching fields,number,dimensions:
Overflow cesspool,number:
Comments: (note c ndition of soil,signs of hydraulic fail level of pondin ,condition of veg tation,
et
i
a
CESSPOOLS• U
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:
_�&
Materials of construction: Dimensions:
Depth of Solids:
Comments: (note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,
etc.)
-6 -
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
SKETCH OF SEWAGE DISPOSAL SYSTEM:
Include ties to atleast two permanent references, landmarks or benchmarks.
Locate all wells within 100 Feet.
20
I
DEPTH TO GROUNDWATER: '
Depth to groundwater: Feet
Method of Determination or pro 'mation:
Lq , 5
Wig
-7-
�10-4ly-OA6WN OF BARNSTABLE
LOCATION L<®1- 7 L,ol-tio-ps SEWAGE #
VILLAGE/ �c,��r ASSESSOR'S MAP Cz OT�� d�
INSTALLER'S NAME & PHONE NO._ ,& 4 �' .�5/r"r (/. f' .24
SEPTIC TANK CAPACITY 15 DDC
LEACHING FACILITY:(type) (size) (1,0 /0
NO. OF BEDROOMS l- _PRIVATE WELL OR=UBLICAT
BUIL R OWNER 11(l VA&,-�,
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED: e5--17— ��
VARIANCE GRANTED: Yes (No�
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. . ASSESSORSNUPNO' C
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s; THE M0NVftWF MASSA HUSETTS
.tr ARP 39IF19P6 E TH
T 5 N OF BARNST LE
Appliratuon for t i)rvv ° yr t, owitrnrtilun� rri nit
Application is hereby made for a Perrot C i s •- c or Repair ( ) an Individual Sewage Disposal
System at:
... a
.sv .. -----•--------7..................................................
�A Location-Address or Lot No.
BA -------------------------------- --------------------------------------•----------------
n o�cn a Address
Installe. Address
OQ .
U Type of Building Size Lot..7..........a
...4.....Sq. feet
Dwelling— No. of Bedrooms__________________�------__--___-_.._--Expansion Attic ( ) Garbage Grinder ( )
per., Other—Type of Building ____________________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( )
a - ..................... ----- ....................---------------------y--..'_...----.--.•-•-•-......----•---••-•-••-------------'..p...`.
d Other fixtures ___ ____ _____ ___ _ _ , _ J� _y
W Design Flow........... ���gallons per person per day. Total daily flow__:................................gallons.
WSeptic Tank—Liquid capacity__�___�galIons Length.IL"__4_-_ ��idth�__Z... Diameter----- Depth-�_._:.�......
x Disposal Trench--No- -------------------- Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No............... --Diameter......./1_,----- Depth below inlet....... '........ Total leaching area...4 _.....sq. ft.
Z Other Distribution box ( ✓) Dosing tank ( ) _
Percolation Test Results Performed by..___7� _4_.. ............. Date_14: :.96...............
Test Pit No. l is minutes per inch Dep lI of Test Pit----/.Z-....... Depth to ground water........ . _........
44 Test Pit No. 2...............minutes per inch Depth of Test Pit-----1%°___----- Depth to ground water..........
--•-•-••--�---------------•--....-•---......--:--...----•-•--........._....-........-..---•-•---..........................................................
O Description of Soil... A.. r '�` `x'�,�... -'-�i3`._'-$ ----•--•----------•-----------•-----•----------------------••-
V ....--•------------------------••----------. ..............
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 TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance has beenY./I
' the board of health.
Signed ........�� � � ... ...................................................... .......... ..._ '� !: ..
Application Approved By --------- ............ .....
Application Disapproved for the ollowing reasons: . . . .......................................................................... ................. .
....... . .............. ........................ . . ... .... ........... ... .................................................... .. ..................... ................... ............. ...
Permit No. -------- ...-...�.�?.. ..�� Issued ..-�p......
................... ..........- ace `..��......te......
0\
9
F ............
THE COMMONWEALTH OF MASSACHUSETTS
EB
BOARD OF HEALTH
TOWN OF BARNSTABLE
Appliration for Diripotial Works TonAftrurtion Ilermit
Application is hereby made for a Permit to Construct 'or Repair an Individual Sewage Disposal
System at: '9 1
.....................I-A
. ...................................... ...................................................
Location-Address or
----------------------------*-------- ----------------------------------*....... Lot No..A'd-,d'r',c,s,s.....*"'*-----------------
............. ...............................................................*----------------"---------
Installer Address
Type of Building Size Lot..�--- ...........Sq. feet
U
Dwelling—No. of Bedrooms...................J�---------------_--.-Expansion Attic Garbage Grinder
aOther—Type of Building ---------------------------- No. of persons._______....._.._......._... Showers Cafeteria C� Other fixtures ----------------------------------------------------------------------------------------------------------- ..........................................
-
Design Flow________________________________---S.5, gallons per person per day. Total daily flow_'�>................................gallons.
9 Septic Tank—Liquld capacitv! gallons Length./An4--- Width'4_... Diameter-----7n ... Depth..577--9.....
Disposal Trench--No. .................... Width_........._.______.. Total Length...._....___........ Total leaching area....................sq. f t.
Seepage Pit No---------_- Diameter.......1/-------- Depth below inlet.__....!��........ Total leaching area....44,4.....sq. f t.
Z Other Distribution box ( /) Dosing tank ( )
Percolation Test Results Performed by._... 4. .............................................. ...............
14 Test Pit No. l�!:_!:.Z__ _n-iinutes per inch Depth of Test Pit----/_Z- ...... Depth to ground water..__....."............
Test Pit No. 2...............minutes per inch Depth of Test Pit-----_//.......... Depth to ground water.._...."`:.......
04 ............;;.;.................................4.............................*--------------*-------------------------- ..................
/Iv, -
0 Description of Soil..T7*,�....../............�L....
W )f - ... ... ............... ................................................. ..............................
U .................................................................... .............. .......................................................................
W
Z ........................................................... ..........................................................................................................................................
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 TITLE 5 of the State Environmental 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 ........ .............................. ------
----- ...... ........................... .......... .... ............
D
Application Approved By ......
...................................._..................I..............
....................I.......... D�
Application Disapproved for the reasons:-,........................................................................................................................................
................................................................................................................................................................................................................ ........................................
Permit No. ........7,57., [02S_ /................... Issued ---------- ---- 7
. ..................
--—-------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
(11,ertifirate of Q-11amplianre,
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed or Repaired
by ....................... ------------------------------------------------------------------_....... ...................................................................................................
Insr,Jlcr
at ---------.......... .r7------------ . .I.... AJ--------------- 11_ 7 L ...........F - ...................................
has been installed in accordance with the ffrovisions of TITLE 5 of The State Environmental Code as described in
the application for Disposal Works Construction Permit No. I.c
)...1.t AS A GUARANTEE THAT HE....... dated ...
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE -----------------................ lnspect4�_
-------------------- -----------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE 2 No...j,�i....faa L/ FEE.... C)......
Difilinsal Workii (lomitrudion "ermit
Permission is hereby granted.............. ;, Z------------------------------------------------------------------------- -- ............
to Construct (\ or Repair an Individual Sewage Disposal System I
at No........
....7�------ ) - . . .......
Street
as shown on the application for Disposal Works Construction Permit No.73__:'11)_)_ Dated____. 5......U
..................................Z)-Board-o-f-H-ealth------------------------------------------
DATE.................... ..........................
FORM 36508 HOBBS 6 WARREN.INC..PUBLISHERS
No.- ��= -- Fee----s�-'- ----------
BOARD OF HEALTH
TOWN OF BARNSTABLE
App[icat ion-*rVeil Con0ruct ion Permit
Application is � Lade for a permit to Construct (i/), Alter ( ), or Repair ( )an individual Well at:
/� L,oras Q
• e e�Ls- D U U Z
� v .l R.v,o �
Location — Address Assessors Map and Parcel
JAM!!;; _ / wta 0z63Z�
Owner ^/ Address
-----�fff---------------------------- ----------a-------------_/l�I�a------------------------------------------------
Installer — Driller Address
Type of Building
Dwelling
Other - Type of Building ---------------- No. of Persons--------------------------------------
_�! r
Type of Well— —- =Z -G - ----— —-----
Capacity---— -
Purpose of Well---- CJs�'►CS-72__L-----------------------
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 ertificate .of Compliance has been issued by the Board of Health.
Signed _-,�c" ---------------------------
date
Application Approved By-- _ 7
-- 'L°�w`�— —— —— date
Application Disapproved for the following reasons:---------J--------------------------------------------------_________
-------------------------_-- - — ----- - — - - -------------------—- - -- — ------
date
Permit No. Issued--- -- i- -`� ---- --- -
date
BOARD OF HEALTH
TOWN OF BARNSTABLE
Certificate Of Compliance
THIS IS TO CERTIFY, That the Individual Well Constructed ( ), Altered ( ), or Repaired ( )
by--------------- — -----------------------------------------------------------------------------------------— - --- —--
Installer
at------- - --- AZ- -------------------------------------------------- - ------------------------------------
has been installed in accordance with t e provisions of the Town of Barnstable Board of Health Private Well Protection
Regulation as described in the application for Well Construction Permit No. - - >�=--d2- ----Dated ----�_�'�
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL
SYSTEM WILL FUNCTION SATISFACTORY.
DATE --- - --— --- — - - — — -- Inspector---------------------------------------—--- - ----
{�,.���"yr � t'.��-..,r�...,�,y,�'kt4""ri�Ui 'r �'�'^f'''4-v-'Jr'1�1�s.,�.�^w..r.,.r fiy.••,rti�.'1ri,r,w�.hi^J 'r}4�l /'X'�'-T-.^ry,!' �.��`rii.'""'+��,ya�y[�.�.,�Y,a?�w._.,�.�y `..�.1 Sr r t in
No pTee---
BOARD OF HEALTH ;
`TiOWN OF BARNSTABLE
App[icat ion ArMelt clCon.5truct ion Permit
Application ish ade for a permit to Construct (t/); Alter ( ), or Repair ( )an individual Well at:
Location.— Address i Assessors Map and Parcel
Owner Address
L _ __ f f8------------------------------- _p e—1 - -
--- - -
Installer Driller Address
Type of Building -
Dwelling �4 � w_1 t_ ----_ !• c _
Other - Type of Building--------------------------------- No. of
Persons--------------------------------
'TYpe of 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.
Signed
date
Application Approved By - -- - ",; -- -= =y�-- � -- -- � ---- ---- s date
Application Disapproved for the following reasons:---------------------- ---------
----------------------------__--- — ------- -----------
-- -----------------------------------------------------------------
Y date
Permit No. --- ---------
date
a
BOARD O'Fy HE4'L'"TH:
z'
ti T O ' <'B"A`1�.i S T A B L E �~ `
Certificate Of (LompCiance
THIS,IS TO CERTIFY, T at the ndividua Well Constructed ( ), Altered ( ), o?Repaired
by --- - - �t n .�+-------- ------------ -- ----------------------------- ---------- - - ---=-----
s Installer
at------- � - --- v - :-=---- --- ----------------------------------------------------- ---------------
has been installed in accordance with tFie provisions of the Town of Barnstable Board of Health Private WelhProtection
Regulation as described in the application for Well Construction Permit No. --W--�=---rZ_-t---Dated
'-
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL
SYSTEM WILL FUNCTION SATISFACTORY. >"'
DATE----------- =i"= - _�-- - -- Inspector=_--- - - — - - --- --
�st ,..�"` �.�' �...� r �
-- �---�.mr am..eQ.�.�os�+,aoo e...+..a..�,...,...�_/..o..�.r.M..�.�e.�rm++�u:.�..i..�..�...�a.m�-.®.�..,��v���..��.r.v..da.�.e.�...�.•�s�e:.�.
BOARD OF HEALTH
TOWN OF BARNSTABLE
Melt Congtructionpermit
No. ---- "-` __ ( Fee-
Permission is hereby granted- � -----— - ------ - -- -
f to Construct '( Alter ( ), or Repair ( ) an Individual Well at.
No - - -- - — - ----------------- - -= -- -- - -
Street
t
as shown on the application for a Well Construction Permit
I
No. --------`={-Z-d -= ----- —- - - Dated---- -" _ -- - -
— —r ----------------- - ------
- Board of Health
17 A~
DATE---- }-=- -- - -��-- -- --------- 1
I, 4�
1 �
e n
• y 1
ENVIROTECH LABORATORIES, INC.
MA Cert. No.: M-MA 063
449 Rte. 130 • Sandwich, MA 02563
(508)888-6460 ' 1-800-339-6460
FAX(508)888-6446
CLIENT: Bob Carlton LOCATION: Lot 7
ADDRESS: Lothrop's Lane
W. Barnstable, MA
SAMPLE DATE: 4-10-95
COLLECTED BY: L.Wile Wells DATE RECEIVED: 4-10-95
TIME: 7:OOAM LAB I.D. NO. : E4-103
JOB TYPE: New Well SAMPLE I.D.NO. 7
WELL SPECS. : 120' 4" PVC
81' to water
FLOW: 10 G.P.M.
RESULTS OF ANALYSIS:
Parameters Units Recommended Limit Result
Coliform bacteria/100ml (MF Method) 0 0
pH pH units 6.0-8.5 6.83
Conductance umhos/cm 500 94
Sodium mg/L 28.0 8.3
Nitrate-N mg/L 10.0 0.08
Iron mg/L 0.3 0.21
Manganese mg/L 0.05 0.011
Volatile Organics ug/L See enclosed report.
EPA Method 601/602 None detected.
COMMENTS:
Yes No WATER IS SUITABLE FOR DRINKING URPOSES R PARAMETERS TES ED.
XXX !� >
Date T 6
Ronald J. ari
Laborator irector
LT = Less Than
__ y•� rrn : 1rVurvUwA't'`:K ANALYTICAL ENVIP�OTECH- - -- - -
GRQufitDWATER
ANALYTICAL EPA METHODS 601 and 602
Volatile Organics (GC/PID/ELCD)
Lab ID: 10389-01
Field ID: E4103 Batch ID: VG2-0594-W
Project: Carlton/Lot 7 Lothrop Sampled: 04-10-95
Client: Envirotech Received: 04-10-95
Cant/Prsv: 40mL VOA Vial/HC1 Cool Analyzed: 04-12-95
Matrix: Aqueous
CONCENTRATION REPORTING LIMIT
PARAMETER (ug/L) (ug/L)
BRL 5
Dichlorodifluoromethane BRL 5
Chioromethane BRL 5
Vinyl Chloride BRL 5
Bromomethane BRL 5
Chloroethane BRL 1
Trichlorofluoromethane BRL 1
1,1-Dichloroethene BRL 1
Methylene Chloride BRL 1
trans-1,2-Dichloroethene BRL 1
11
1-Dichloroethane BRL 1
cis-1,2-Dichloroethene * BRL 1
Chloroform BRL 1
1,1,1-Trichloroethane BRL 1
Carbon Tetrachloride BRL 1
Benzene BRL 1
1,2-Dichloroethane BRL
Trichloroethene BRL 1
1,2-Dichloropropane BRL 1
Bromodichloromethane BRL 5
2-Chloroethyl Vinyl Ether BRL 1
cis-1,3-Dichloropropene BRL 1
Toluene BRL 1
trans-1,3-Dichloropropene BRL 1
1,1,2-Trichloroethane BRL 1
Tetrachloroethene BRL 1
ibrom ochlorome thane 1
D BRL
Chlorobenzene BRL I
Ethylbenzene BRL . 1
meta-and Para-Xylene * BRL I
ortho-Xylene * BRL 1
Bromoform BRL 1
1,1,2,2-Tetrachloroethane BRL 1
1,3-Dichlorobenzene BRL 1
1,4-Dichlorobenzene BRL 1
1,2-Dichlorobenzene -
SPIKED MEASURED RECOVERY QC LIMIT
QC SURROGATE COMPOUND
30 30 100 % 87 - 113
a,a,a-Trifluorotoluene 30 34 112 % 83 - 117
1,2-Dichloroethane-d4
BRL = Below Reporting 6 Limit.Purgeable Aromatics, 40 compound.
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