HomeMy WebLinkAbout0027 OLD TOLL ROAD - Health 27 Old Toll Road
A= '109-070
\ West Barnstable
LOC TION S E W A GYZ,
ERMIT N0.
_ ' .-� T-7 1 fd %f
VILLAGE O
lo
INSTAL ER's //NAME & ADDRESS
e UILDEIt OR OWNER
DATE PERMIT ISSUED
DAT E COMPLIANCE ISSUED 79
C'Ily
36�6,�
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OR
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No. W v t Fee �S
BOARD OF HEALTH
TOWN OF BARNSTABLE
01ppYication jFor Vern Construction permit
Application is hereby made for a permit to Construct(�, Alter( ), or Repair( ) an individual well at:
Location-Address Assessors Map and Parcel
er Address
� iri /�/
�p. fNS
Installer-Driller Address
Type of Building
Dwelling
Other-Type of Building No. of Persons
Type of Well ����e JD /z, Capacity -
Purpose of Well
Agreement:
The undersigned agrees to install the afore described individual well in accordance with the provisions of the
Town of Barnstable Board of Health Private Well Protection Regulation-The undersigned further agrees not to place the
well in operation until a Certificat of Com lia has been issued by the Board of Health.
Signed f ./`9-*
Dater ��
c 0//(CJ
Application Approved By 0 '
Date
Application Disapproved for the following reasons:
�j3 r Date
Permit No. Issued f
Date
--------------------------------------------------------------------------------------------------------
BOARD OF HEALTH
TOWN OF BARNSTABLE
Certificate of Compliance
THIS IS TO CERTIFY,th/at/the individual well Constructed(1(), Altered( ), or Repaired( )
by /77,07
, Installer
at �� d�a �O/� P,( A &-item
has been installed in accordance with the provisions of the Town of Barnstablp Board of,Uealth Private Well Protection
Regulation as described in the application for Well Construction Permit No. ,2 6- 0 0 Dated
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL
SYSTEM WILL FUNCTION SATISFACTORILY.
Date Inspector
6�
No. �0 ( (D ^ 00 Fee
r BOARD OF HEALTH
TOWN OF BARNSTABLE
ZIppYicatiou _for Vern Cous�tructtou Permit
Application is hereby made for a permit to Construct Alter( ), or Repair( ) an individual well at:
Location-Address Assessors Map and Parcel
Owner Address
Z&amend 1411
Installer-Driller Address
Type of Building
Dwelling
Other-Type of Building No. of Persons
Type of Well -i9 141cl, Capacity �/j >41h'�
Purpose of Well
r
Agreement:
The undersigned agrees to install the afore described individual well in accordance with the provisions of the
Town of Barnstable Board of Health Private Well Protection Regulation-The undersigned further agrees not to place the
well in operation until a Certificat of Commplian^ce has been issued by the Board of Health.
Signed z (.,r rr //E/1'4/ !
Date
Application Approved By. C)
Date
Application Disapproved for the following reasons:
((�� Date
Permit No. _ `' Issued ICJ
Date
BOARD OF HEALTH
TOWN OF BARNSTABLE
Certificate of Compliance
THIS IS TO CERTIFY,that
/the individual well Constructed(4), Altered( ), or Repaired( )
by OGo/2-74ri `fJ / aAQ166rz--i-z;L
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'tfie application for We1L'Construction Permit No: l ao(6 G3y Dated
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL
SYSTEM WILL FUNCTION SATISFACTORILY.
Date Inspector
BOARD OF HEALTH '
< j
?,TOWN OF BARNSTABLE
µ --0 0 lVell Con.5truction permit
w No.. Fee
Permission is hereby granted to �m/rn� b h d0/6c1 h
Installer
to Construct(✓�), Alter( ), or Repair( an individual well at:
No. r1 ��d /"C X)• 6L t.a�-"le_._
Street
as shown on the application for a Well Construction Permit Nd��d16 Dat
Date ( � 1 `� Approved By
t
h Massachusetts Department of Environmental Protection
Bureau of Resource Protection
Weli Completion Reports
Well Driller ,
. m
Please specify work performed: Address at well location:
........................................................................
New Well Street Number: Street Name: t-+
27 OLD TOLL ROAD
'v
Please specify well type: Building Lot#: Assessor's Map#: $
Domestic 109CA
Assessor's Lot#: ZIP Code:
Number Of Wells: 070 02668
Cityrrown:
Well Location BARNSTABLE
In public right-of-way: GPS
Yes t` No North: West:
E __.i
41.70894 70.39857
Subdivision/Property/Description:
Mailing Address:
click here if same as well location address'
....................................................................................._..............................................................
,
Property Owner: Street Number: Street Name:
RICHARD KERVIN 27 OLD TOLL ROAD
City[Town: State:
Engineering Firm: BARNSTABLE MASSACHUSETTS
ZIP Code:
02668
Board of health permit obtained:
f Yes (7 Not Require
Permit Number: Date Issued:
W2016 030 10/19/201.6
j` Massachusetts Department of Environmental Protection
LLI- 1�
Bureau of Resource Protection-Well Driller Program
Well Completion Reports(General)
Well Driller -General Well Form
DRILLING METHOD
Overburden Bedrock
r► Kug�ger Choose Bedrock--
...._._..._. _�____���
WELL LOG OVERBURDEN LITHOLOGY
lFrom(ft) To(ft) Code Color Comment Drop in drill- Extra fast or slow Loss or addition
stem drill rate of fluid
20 Fine To Coarse S Brown WW tom`Fast Slow
YES NO Loss Addition
�NO
F�Lo
7Addition
Fine To Coarse S Brown • mm YE _. ss
f, __..._.._.. I (;
(40 1 60 Fine To Coar se S + (Brown ' Fast Slow Loss Addition
lYES NO (((
60 80 Fine To Coarse S Brown •�. 17. 111- Fast f"Slow I,
YES NO Loss Addition
............................................................................................................................-................................................................-......._...........................................................................................................................................................................:::::::::::::::::::::::::::::::::::::::::::::::::..:.F
-�,
I t
80 (100 (Fine To Coarse S Brown ±� ! f"Fast Slow
. L.__ _ __ YES NO [ ..._.... ... ........ Loss Addition
_._._ __..__..._. v _ ..
10012p Silty Sand- � Brown ( f�Fast Slow
YES NO t ..... Loss Addition
�120130 — Silty Sand _ Brown Fast Slow
F—�ESNol
_..., Loss Addition
=YESNO
Silty Sand Brown Loss Addition
150 165 To Coarse S Brown Fast Fine Slow
[YES NO Loss Addition ]
WELL LOG BEDROCK LITHOLOGY {
......... _....-Loss or Extra
rDrop in Extra fast or Visible Rust i
[Fro,,(ft.) To(ft) Code Comment addition of 'Largedrill stem slow drill rate fluidStainingChips
W.... i _ ._...
Choose Code + Yes s Yes
DYESNO Fast Slow Loss Addition
ADDITIONAL WELL INFORMATION JJJ
Developed 'Yes No Disinfected Yes f No
Total Well Depth 165 Depth to Bedrock
Surface Seal Type iLNone racture Enhancement 1 Yes No�
CASING W Is Casing above ground? From: 1 To: 0
From To Type Thickness Diameter Driveshoe
...........
0 161 Polyvinyl Chloride Schedule 40
..,...� - _ _.-..�. L W �
SCREEN jff No Screen
1
Massachusetts Department of Environmental Protection
Bureau of Resource Protection—Well Driller Program
Well Completion Reports(General)
.
___._.- _._.__
i From To Type Slot Size Diameter
161 � 165 � �Stainless Steel Well Point
WATER-BEARING ZONES DRY WELL
.....e-..... _ x. ....�...............
From To Yield(gpm)
165
PERMANENT PUMP(IF AVAILABLE) _
2 Wire Constant Speed _.
Pump Description Horsepower
i
;Submersible
.....W.._..............
Pump Intake Depth(ft) 145 Nominal Pump Capacity(gpm) 9
ANNULAR SEAL/FILTER PACK
..................... ._..........__.... ........................................................................................................................................................................................._.................................................._....
.........
............................
Water Batches Method Of
From To Material `Weight Material (Weight
(gal) (count) Placement
Choose Material ) i; Choose Material (( Choose One +�
.......�........ _ ^. I _ I
WELL TEST DATA
Time Pumped Pumping Level(ft Time To Recover Recovery(ft f
Date Method Yield(gpm)i
(HH:MM) BGS) (HH:MM) BGS)
_...._....,,..,.a__ .
�
10/27/2016 (Constant Rate Pump 19............._ I.. 1:30 124 ) 0:01 116
WATER LEVEL
LStatic Depth BGS(ft) Flowing Rate(gpm)
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.
DESMOND
THOMAS E Monitoring[M] Supervising Driller III,
DrillerDESMOND III Registration# 764 Signature THOMAS,E
Massachusetts Department of Environmental Protection
` Bureau of Resource Protection—Well Driller Program
Well Completion Reports(General)
DESMOND WELL _
Firm DRILLING INC... Rig Permit# 023 Date Job Complete 10/28/2016
NOTE:Well Completion Reports must be filed by the registered well driller within 30 days of well completion.
AsBuilt _ - { Page 1 of 2
OJIT n�� Q SEWAGE 37PERMIT NO.
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VILLAGE
INSTAL 'ER''�SS- NAME Q ADDRESS
7ti tic vLct Ju% S'� S p_-.��x-.'✓f 1 U✓✓iCr-fin
IIUILDER OR OWNER
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED1 - 7- 79
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http://issgl2/intranet/propdata/prebuilt.aspx?mappar=109070&seq=1 10/19/2016
7
No................ly 7%7 'Flcs....d✓r
THE COMMONWEALTH OF MASSACHUSETTS
BOARD O HEAL H
f rt. ............ .... ..........OF.......
.... .
Appliration for Ui ipoii al Vorkg ( omtrurtiun ramit
" Application is hereby made for a Permit to Construct ( &I or Repair ( ) an Individual Sewage Disposal
System at:
/ j
---��-P--------------------------
. - ---- .........
Locati n Address o No
-- 'f� E 17..... 1
T�Owner Address
W .o_.[/. -------- D9A.)P&)1e1/. y.
Installer Address
dType of Building Size Lot....,1 .._fi_.^.._____Sq. feet
Dwelling—No. of Bedrooms............... ...........................Expansion Attic ( ) Garbage Grinder (I/j
p., Other—Type of Building............................. No. of persons............................ Showers ( ) — Cafeteria ( )
Q+ Other fixt res .---------•-•---- ------------- .
Design Flow.......... ______________________ allons per person per day. Total daily-fiow__._...... uCj......_............gallons.
W -
WSeptic Tank IL Liquid capacity_./S . allons Length................ Width................ Diameter---------------- Depth................
x Disposal Trench—No..................... Width_..../............ Total Length.................... Total leaching area..............
. --sq. ft.
Seepage Pit No--------7.,.:_...... Diameter.._....1_�,__. Depth below inlet............... Total leaching area....�.c�.��_.sq. ft.
Z Other Distribution box ( ) Dosing tank
Percolation Test Result Performed by................................... ............. Date.....-.. '7�.......--....
Test Pit No. 1.. ___.._..minutes per inch Depth of Test Pit.................... Depth to ground water........................
W
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
x - - --------- -/-- ----- ---
- - -- ---------- - ................
o •. l _ i....: .
Description f S Il �.....�� ¢� J ``
/j9f�f 7 ..
Il .......... .. `--_.3KJ[- _. JJl�.. ._ ._ .__ .. ... _ _. ............................................... .
W VV/ �/Il� 1 .. -------- . . V - :- - -
UNature of Repairs or terations—An wer1 �h n applicable______._ ........................................
...-•----•••--------------------- -•-- ,��.� ....N ...... 4....... ...----------.._.
Agreement:
LL r f .
The undersigned agrees to install the of r di &du described I al Sewa e Disposal System in accordance with
the provisions of iITi v 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.
igned ... .....A.. ..... ........---.......---..........•---•.....-• -•----- --
Application Approved By........ _
Date
Date
Application Disapproved for the following reasons:........................................................................................................ --•--
...........................•-------------••-•---------------------------------•------------••---------------------------•-•-----••-•-•-----------••---------------------•----•-•----•--•--•----•--;..---
Date
PermitNo......................................................... Issued----- '_ .......................
Date
No........ ."7A. k R Fss.. 5.14---
1�,, -.
THE COMMONWEALTH OF MASSACHUS'ETTS
-,.,, ,BOARD ,OF HEALTH
�,.
----------------- .......
c .r.. ...OF......
Appliration for BlifVomi al Works, Towitrurttun rautit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
Systr
................ " �. . . = -
��}} �}} ,�
Lafll�>� res :. or�drtW"''*. - �+C
• � ------ --------------•------------••-------
.. •--
°r "installer � Address �J�l��'�l�*1�.
d Type of Buildine Size Lot___________________________Sq. feet..,
Dwelling—.,No. of Bedrooms.......... Attic ( ) G ag4e 17rinder
per, Other—Type of Building ....._......... --------- No. of persons____________________________ Showers ( ) — Cafeteria
s: Other fixtures - = --------------------------------------•-•
WDesign Flow__________________________.................gallons per person per day. Total daily flow.._.__._____.____._____...................gallons.
04 Septic Tank—LiquX1 pacity............ lions j Length�P______________ Width................ Diamete>�.��__._.Depth____._____.._..
x Disposal Trench—�.�To. ...._......._..... Widthf` __ ,_____-_. Total Length....... Total leaching area sq�ft.
sq. ft.
3 Seepage Pit•No_____________________ Diainet,2r _-_____-_--_____ Depth belov inle�y___ Total leaching area....�.7. _sq. ft.
/7' V
Z Other Distribution bo ( . ) t �osii* tank ) u `
Percolation Test Res s Performed y _. ________ S. " _____..____. Date a"`t`� ...__..__._:
aTest Pit No. L__ ...........minutes per in Depth f ,Test P, Depth to ground' ter_--
(i Test Pit No. 2.....- minu es p r inch'VDepth ,of _T Prt� s D pth to gr ,und Ovate f
.e ----- `..
D sa3gn i �r
�1_.tom. 1 ----••-•--
- y »
W r.
U Nature of Repairs or Alterations Answer when applicable, .__._ .............. �._.._...___:...___ l.........................
_.. ... 7. y, -vt
- � --- ---fit--- -- --
Agreement:
The undersigned agrees to install the aforede cribed Individual Sewage Disposal System in accordance with
the provisions of'LIT L '
p5 of the State'Sanitary Code—The undersigned furt�'er agrees not to place the system in
operation until a Certificate of Compliance has been issue4by the board'othealth. '
.........................................1 --------
Application Approved B
Date
Application Disapproved for the following reasons:......................... -••---------------------------.......................................................
••-•--•---•-•-••••-•---•......---••---•••-•-••-----•-•--•-•-••-••-......-••--•--.....:.--•--••••-----••-•.--------------•---------•--•-----------•......--------------..................................
Date .v
PermitNo.......................................................... Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOA OF, HEALTH `
....................................:.....OF.................:....................................................................
rtif iratr of TompliFanrr, v'
C ndividual Sewage Disposal System constructed ( ) or Repaired
by %' -------------•---
k.....
fi
at...................................................... ................_........ .-•--------•-........................•••••-
has been installed in accordance with the provision o T J 7,�T The State Sanitag, 6414 as Wibed`in the
application for Disposal Works Construction Permit No......................................... d-ated
THE•ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACfO`RY. r'
DATE............................ ......-•-•......................................... Inspector.....................................................................................
THE COMMONWEALTjq OF MASSACHUSETTS '
e
BOAR ALTH77
:, J
..................................OF.....................................................................................
No. ..................... FEE........................
. �.
Big , n• rrnt'
_ r sion s Ab anteto Tact ) p r ' n lit vv Sol S�Y"
at No. '".
-------------------- : -----•-_-- -------- --•-_-----------•----tr t
Street
as shown on the application for Disposal Works Construction Permit,;No..................... Dated.._....................:, ............
�1DATE . / / ]./- •-- ..
FORM IZ55 HOBBS & WARREN. INC., PUBLISHERS
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D I S T R I B U TI ON OX tab"COVERS .N
� NOTE ALL SYSTE►� COMPONENTS SHALL BE CONSTRUCTED AND
NO SCALE INSTALLED IN ACCORDANCE WITH T ITL_E S OF THE SrATE
,4 1 R SPACE - ►B" Come. Prta -
♦ EJJVI RoME"T-^t-. CODE ( 19'77) AND ANY APPLI CABLE LOCRL 2ULES.
DESIGN DATA
rw v y.t� r>kno 10S k s. 4 0 x- 1 C-7ALS
2'.0' 3 — % 2 _ O� Q /".��1 u USA ', ` ����.c. Kf _ 171SPOS4J
L L ABRRON FOVNO irr- b -- r3 RElwf Ba*3 I t�
y m' I r Top sSertOM ! L✓tE �rG
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NO SCALE SEWAGE DISPOSAL SYSTEM
J4�
ES TO BE _
a
i .. . i 1t1'-'-
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