HomeMy WebLinkAbout0045 PERCIVAL DRIVE - Health 45 PERCIVAL DRIVE
WEST BARNSTABLE
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BOARD OF HEALTH
TOWN OF BARNSTABLE
ApplicationArVell Cootructionpermit
Application is hereby made for a permit to Construct ( ), Alter ( ), or Repair ( )an individual Well at:
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Location — Address Assessors Map and Parcel
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Owner g — Ad ress ?
Ilk
Installer — Driller Address
Type of Building
Dwelling--------------------------------------------------------------
Other - Type of Building ------- No. of Persons---------------------------------
_ of
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— - -- --�` = �{
—_—_}b� `�---------- date
Application Disapproved for the following reasons:------`e+----------------------------------------------------------------------------
--- ------------------------------------------------------------------ ---
date
Permit No. 5-7 - ---- Issued--- -- - - - --- -------- --
date
BOARD OF HEALTH
TOWN OF BARNSTABLE
Certificate ®f Compliance
THIS IS TO CERTIFY, That the Individual Well Constru ted/rl , _Altered ( ), r Repaired
bY- --------- -- - - ---- - - ---------_A_ -
Ins alter
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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. ^-��^�C_Dated----------------------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL
SYSTEM WILL FUNCTION SATISFACTORY.
DATE ---- --- —------------------ - - -- Inspector-----------------------------------------— -- ------------
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BOARD OF HEALTH
TOWN OF BARNSTABLE
",21ppticat ion ArWell Con0ruct ion Permit
Application is hereby made for a permit to Construct ( ); Alter ( ), or Repair ( )an individual Well at:
----------45------ ' --
Location — Address Assessors Map and Parcel
-- — Owner �' Ad ress ' -
- InstallerIK
¢` '— Driller ?`, --k— - - Address
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Type of Building
Dwelling-------—-----—----------------------------------------------- {,
Other - Type of Building----------------------------------- No. of Persons----------------------------- — --------
--- ----- ---- —
Type of Well------------------------------------------- Capacity--------------- .
Purposeof Well---------—------------------------------ ----------------
i
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�G � -- -r� LJ�� ZAA -
a
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Application Approved By--___ - � — —-- -— �� L�
y date
Application Disapproved for the following reasons:-----------------------------
------ -------------------------------------------------------------------
date
w C'� �� -- ---— - - Issued--- --
Permit No. --- _L_1 --- - date - ---------------------------
date
BOARD OF HEALTH
TOWN OF BARNSTABLE
Certificate (VIDf (Compliance
THIS ISS TO CERTIFY, That the Individu/al Well Constructed _Altered'( ), or Repaired
�
by- b F -� ------- ��� - --- - - - -- ---—---
InItaller
s
--------------------------
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 Noll - — --Dated ----------
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
Melt Construct ion Permit
4;
No. "1f Fee -------
Permission is hereby granted
to Construct ( ), Alter ( ), or Repair ( an Individual Well at:
street
as shown on the application for a Well Construction Permit
47
No. ------------— --- - ------------- - Dated---- — -, —
-------------------- --------------------------------------------------------
Board of Health
DATE
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Town of Barnstable I'# I v
Department of Health,Safety,and Environmental Services
Public Health Division Date
367 Main Street,I lyannis MA 02601
HARMABIA
KAM
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Soil Suitability Assessinent for Sewage Disposal.t
Performed By: T ffom A f m c(,f u4 tv PP t• witnessed By: eokV o �An
LOCATION & GENERAL INFORMATION
Location Address Owner's Name A1.4T j- MV N�
toy 41 PE W V1J i" O tU V Address
Assessor's Map/Parcel: i b/ I'ZL Engineer's Name DIrM 'I-ES'e
NEW CONSTRUCTION REPAIR Telephone ` Id
1 F� �0 u(.►Jt'U�
Land Use � )� Q`��1 A�:-- Slopes(%) S ./���J�� Surface Stones
7
Distances from: Open Water Body �6T R Possible'Wet Area ~R Drinking Water Well
Drainage Way/1J0
/0 /J10 R Property Line d� t R Other It ;
SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes)
/V �1
N
ti
Ty Z
00 ValN
J�
18,,6.s51 � Jou
Parent material(geologic) O(Jf t"14 S(,Za- Depth to Bedrock
Depth to Groundwater: Standing Water in Hole: /"m"F Weeping from Pit Face
Estimated Seasonal Iligh Groundwater AA
DETERMINATION FOR SEASONAL HIGH WA`I'ER.TABLE
gI'
Method Used: /"147�
Depth Observed standing in obs.hole: in. Depth to soil mottles: in.
Depth to weeping from side of obs.hole: in. Groundwater Adjustment R.
Index Well# Reading Date: Index Well level Adj.factor Adj.Groundwater Level
PERCOLATION TEST hate 9=�6•qfilmc
Observation
Hole# Time at 9"
Depth of Perc _ Time at 6"
Start Pre-soak Time c+ Time(9"-6") I s M I/t/ 30 SQL t
End Pre-soak
Rate Min./Inch
Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(YIN)
Original: Public liealth Division Observation Hole Data To Be Completed on Back-j
Copy: Applicant
1
DEEP OBSERVATION HOLE LOG Hole #�_
Depth From Soil I lorizon Soil Texture Soil Color Soil Other
Surface(in.) (Mansell) Mottling (Structure,Stones,13oulderes,
Consistency.° r
d O/R S l- `2 5 H ?/3
2.4% g+
LI
gyp'° ,c 2 �E� �A 2.5 y ,b
DEEP OBSERVATION HOLE LOG Hole# 2
izon . S oil Texture Soil Color Soil Other
Depth from Soil Hor �
Surface(in.) (USDA) (Munsell) Mottling' (Structure,Stones,t3oulderes.
Consistency,
A' L. : Z.5'� 3
ID v 5
sAM) 25 6
DEEP OBSERVATION HOLE LOG Hole
Depth from Soil I lorizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes.
n i ten Y9.9ra el
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil I lorizon Soil"rcxture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,t3oulderes.
Consistency ° Gravel)
Flood Insurance Rate Man:
Above 500 year flood boundary No_ Yes
Within 500 year boundary No ✓ Yes
Within 100 y i hi ear fl ,
flood boundary No— Yes
Depth of Naturally Occurring Pervious Material
f
Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the
area proposed for the soil absorption system? 1
If not,what is the depth of naturally occurring pervious material?
Certification
I certify that on JU v ffi (date)I have passed the soil evaluator examination approved by the
Department of Environmental Protection and that the above analysis was performed by me consistent with
the required trai -ng,expert.se and experience described in 310 CMR 15.017.
Signature _ /W)I� Date- 7