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HomeMy WebLinkAbout0060 PERCIVAL DRIVE - Health w 60 Percival Drive / Barnstable 1 . 1 down cape engineering, inc. SIEVE SOILS ANALYSIS 60 PERCIVAL DRIVE, W. BARNSTABLE DATE OF REPORT: 12/10/19 .JOB : GRAIN SIZE ANALYSIS-SIEVE TEST SITE: 60 PERCIVAL DRIVE, WEST BARNSTABLE LOCATION: DCE TEST HOLE . SIEVE ANALYSIS Weight Sample(Grams): 242.4 SIZE :WEIGHT RETAINED % RETAINED % PASSED (sum ) ------------ .......................................................-------------------- ..................................... 1" 0.0i 0.0%€ 100.0% --------------i......................................................i---------------------------------------- 3/4" 0.0i 0.0%:: 100.0% -------------:......................................................------------------------------------ ---- 1/2 0.0€ 0.0%? 100.0% --------------i......................................................i---------------------r---------_-------- 3/8" 0.0i 0.0%i 100.0% ------------ ................... =------------------ #4 0.0€ 0.0%€ 100.0% -------------i......................................................>---------------------,..................................... #10 22.9 9.4%� 90.6% ........................................................ ;..................................... #20 69.8€ 28.8%€ 71.2% --------------......................................................>---------------------..................................... #40 123.2i 50.8%i 49.2% ------------- .......................................................---------------------:..................................... #50 178.7€ 73.7%€ 26.3% -------------;......................................................}---------------------..................................... #80 209.9i 86.6% 13.4% ------------- ....................................................... #100 218.3:: 90.1 V 9.9% -------------i......................................................>--------------------- ------------------ #200 237.8 98.1%c 1.9% ------------ ...................................................... :--------------------=------------------- PAN: 241.1'i 100.0%' 0.0% ------------- ---------------------------+--------------------- ------------------ SAMPLE: 242.4i NOTE:TEST ON PASSING#4 ONLY, 10.1% RETAINED ON#4 <45% O.K. RESULTS: SOIL CLASSIFIED AS AASHTO A-1-b.(GRAVEL&SAND) (UNCOMPACTED) PERCENTAGE OF MATERIAL PASSING #4 SIEVE : #4 100% (TEST ONLY MATERIAL PASSING #4) OK #5010%-100% OK #100 0%-20% OK �HOFMASsgc #200 0%-5% OK �� DANIELA. yGs SAMPLE MEETS TITLE 5 FILL SPECIFICATION OJALA N >98%SAND CIVILNo.46502 RESULTS: PERMEABLE MATERIAL-CLASS I <5 MINAN. MATERIAL SS ISTE�G�a� NONCOMPACTED N"L SOIL DESCRIPTION: LOAMY SAND W/GRAVEL Commonwealth of Massac�;usetts O&d Title 5 Official l"fiv pection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments , 60 PERCIVAL DR Property Address N HARRIS Owner Owner's Name inforrnation is required for WEST BARNSTABLE MA 8-5-16 =' every Page. City/Town State Zip Code Date of Inspection N Inspection results must be submitted on this form. Inspection forms may not be altered in any4 way. Please see completeness checklist at the end of the form. Important: A. General Information N r When filling out V/ forms on the computer,use 1. Inspector: only the tab key to move your DOUGLAS A BROWN cursor-do not Name of Inspector use the return key. D.A.BROWN INC Company Name P.O. BOX 145 Company Address CENTERVILLE MA 02632 City/Town State Zip Code 508-4204534 S14297 Telephone Number License Number B. Certification 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: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 8-5-16 nspec is Ignature 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. ****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. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form �m Subsurface Sewage Disposal System Form-Not for Voluntary Assessments . 60 PERCIVAL DR Property Address HARRIS Owner Owner's Name information is required for WEST BARNSTABLE MA 8-5-16 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System 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: PROPERTY IS AND HAS BEEN OCCUPIED BY ONE PERSON. SYSTEM MET ALLPASSING REQUIREMENTS AT TIME OF INSPECTION. THIS REPORT DOES NOT PREDICT THE FUTURE PERFORMANCE UNDER THE SAME OR INCREASED USE. 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. Check the box for"yes", "no"or"not determined" (Y, N, ND)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. ❑ Y ❑ N ❑ ND (Explain below): Ens-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 60 PERCIVAL DR Property Address HARRIS Owner Owner's Name information is required for WEST BARNSTABLE MA 8-5-16 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ 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 ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ 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 ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): 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. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that 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 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments , y 60 PERCIVAL DR Property Address HARRIS Owner Owner's Name information is required for WEST BARNSTABLE MA 8-5-16 every page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) 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. 0 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 fecal coliform bacteria indicates absent 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: D) Systems Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® 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 ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 60 PERCIVAL DR Property Address HARRIS Owner Owner's Name information is required for WEST BARNSTABLE MA 8-5-16 every page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® 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. El ® 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 fecal coliform bacteria indicates absent 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 and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® 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. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. 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"yes" in Section D above 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. t5ins-3r13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments N SVey`d. 60 PERCIVAL DR Property Address HARRIS Owner Owner's Name information is required for WEST BARNSTABLE MA 8-5-16 every page. CitylTown State Zip Code Date of Inspection C. Checklist 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? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ 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, depth 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: ® ❑ 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(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins-2113 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments a '< 60 PERCIVAL DR Property Address HARRIS Owner Owner's Name information is required for WEST BARNSTABLE MA 8-5-16 every page. Citylrown State Zip Code Date of Inspection D. System Information Description: SYSTEM CONSISTS OF A 1000 GALLON TANK AND 6 FT PIT AND D-BOX Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ❑ No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ❑ No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ❑ No Water meter readings, if available(last 2 years usage(gpd)): Detail SYSTEM NOT DESIGNED FOR USE WITH GARBAGE DISPOSAL. Sump pump? ❑ Yes ❑ No Last date of occupancy: CURRENTLY Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 60 PERCIVAL DR Property Address HARRIS Owner Owner's Name information is required for WEST BARNSTABLE MA 8-5-16 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: CURRENTLY OCCUPIED Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic 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)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments °r 60 PERCIVAL DR Property Address HARRIS Owne- Owner's Name information is required for WEST BARINSTABLE MA 8-5-16 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 1995 PER AS-BUILT Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑ cast iron ❑40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 2 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑other(explain) TANK IS RIGHT OFF DECK AREA WITH ONE OF THE SONO TUBES RIGHT BESIDE TANK. If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 GALLON Sludge depth: LIGHT TO MODERATE t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 60 PERCIVAL DR Property Address HARRIS Owner Owner's Name information is required for WEST BARNSTABLE MA 8-5-16 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness LIGHT Distance from top of scum to top of outlet tee or baffle i Distance from bottom of scum to bottom of outlet tee or baffle i How were dimensions determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): RECOMMEND PUMPING AT TIME OF TRANSFER AND EVERY 2-3 YRS THERE AFTER FOR MAINTENANCE. Grease Trap(locate on site plan): Depth below grade: feet 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: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 60 PERCIVAL DR Property Address HARRIS Owner Owner's Name information is required for WEST BARNSTABLE MA 8-5-16 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(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 per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts 4 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 60 PERCIVAL DR Property Address HARRIS Owne- Owner's Name information is required for WEST BARNSTABLE MA 8-5-16 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 60 PERCIVAL DR Property Address HARRIS Owner Owner's Name information is WEST BARNSTABLE MA 8-5-16 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 ❑ 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 of ponding, damp soil, condition of vegetation, etc.): PIT WAS DRY AT TIME OF INSPECTION .PIT IS 6 FT DOWN WITH RISERS TO GRADE AND COVER TO GRADE. NO SIGNS OF FAILURE AT TIME OF INSPECTION. Cesspools (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 ❑ No t5ins 3f13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 60 PERCIVAL DR Property Address HARRIS Owner Owner's Name information is required for WEST BARNSTABLE MA 8-5-16 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(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.): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 60 PERCIVAL DR Property Address HARRIS Owner Owner's Name information is required for WEST BARNSTABLE MA 8-5-16 every page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view 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 building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately l5ins•2413 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 «P Commonwealth of Massachusetts Title Official Inspection on Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 60 PERCIVAL DR Property Address HARRIS Owner Owner's Name information is required for WEST BARNSTABLE MA 8-5-16 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ 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 you established the high ground water elevation: Before fling this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts a v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments . 60 PERCIVAL DR Property Address HARRIS Owner Owner's Name information is reequiredquired for WEST BARNSTABLE MA 8-5-16 every gage. Citylfown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Assessing As-Built Cards Page 2 o£2. http://www.townofbamstable.us/Assessing/flMdisplay.asp?mappar=111060&seq=1 8/23/2016 Assessing As-Built Cards Page 1 of 2 f � 1 6r S 9-4N"�' #440 TOWN OF BARNSTABLE LOCATIO �Caf/y A20 V.4c. /Jk SEWAGE# VILLAGE /T. ,#4,Z ASSESSOR'S MAP St LOT/'//=4 INSTALLER'S NAME& PHONE NO.rco fG��l/i°/lissx ,l,f; -assay SEPTIC TANK CAPACITY f 6a c G A�- LEACHING FACILITY:(type) /Q ass &44Z- NO.OF BEDROOMS 'j_PRIVATE WELL OR PUBLIC WATERAJ ecL BUILDER OR OWNER rAR rA DATE PERMIT ISSUED: /le, 9�lf DATE COMPLIANCE ISSUED: �r VARIANCE GRANTED: Yes No A 17 I J.1 AJ 0 .v hftp://www.townofbamstable.us/Assessing/HMdisplay.asp?mappar--1 11060&seq=l 8/23/2016 br "���g #6.0 TOWN OF BARNSTABLE LOCATIO .0 c. EWAGE# VILLAGE &, Xlf d'j,*4049ASSESSOR'S MAP & LOT /'//.-,OJld INSTALLER'S NAME & PHONE NO. c SEPTIC TANK CAPACITY z LEACHING FACILITY:(type) size) i V NO. OF BEDROOMS ,? PRIVATE WELL OR PUBLIC WATERZ✓ eLG. BUILDER OR OWNER rA A Tip A! /-p4 e DATE PERMIT ISSUED: //e DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No ANY-3 Al e P 6, fJ. • No....... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...........10VIA................OF... P kV Appliration for llhipaiial Ifarks Tonstrurtion ramit Application is hereby made fora Bermit to Construct ( �r Repair an Individual Sewage Disposal System at, ............... Rax.tv.A.L-----*0=. ...... ...................................U.T......14.............#4/ mati,. .e or Lot No. f .......... ............ ............................... .................................................................................................. ,ems 4 ,*owner Address ................jt Installer Address U Type of Building Size Lot...........................Sq. feet Dwelling—No. of Bedrooms...............3.......................Expansion Attic Garbage Grinder ,.-I 04 Other—Type of Building ............................ No. of persons............................ Showers Cafeteria 04 1 Other fixtures ........................................................................................................................... Design Flow....................55. gallons per person per day. Total daily flow.............................IS....0-----*g'*a"I'I"o---ris". W =..gallons Length................ Width__............._ Diameter._-__-__-___---- Depth...._...._..._.. 1:4 Septic Tank—Liquid capaci­�------------ Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. f t. Seepage Pit No.__------- ----- ---- Diameter-----1.0.------- Depth below inlet......... ....... Total leaching area..!&&...sq. ft. Z Other Distribution box Dosingtank Percolation Test Results Performed by._.... OYLE......E.06.1ju.62u {� ....... Date..........9-.t�-s&...... Test Pit No. I................minutes per inch Depth of Test Pit.._.._...........__. Depth to ground water--_-_-_-_-___-__---__.-. Gz, Test Pit No. 2................minutes per inch Depth of Test Pit.............__..... Depth to ground water..._._._............_... ----------------;. 0 Description of Soil.............. o. ------------------------------------------1..! li...... ....6*1.4u ....................................... ....................................................................................................................................................................................................... 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 Peen 1 01"1 y the boar f h 0"4 - - Signed .... ...... ............ .....4Q2.C ApplicationApproved By ... ..... ...... ... .. .......... ­ -------------- -- -- -------- ----1----------------- - ... ...... .............. ---- Application Disapproved for the following reaso - --------------------------------..............................--------------- ............. ....................................... .......... ....�2... ---------------------------------------------------------------------------------------------- ................ Permit No. .... .... .. ...... ------------- Issued .--------------------- i k • • No..............! '. + 1' �' Fizz.............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .....l O -4.................OF... �P...C2.��T P. ........................................ Applira#iou for Dispoii al Workii Tomitrnrtinn ramit Application is hereby made for a Permit to Construct ( ✓°)or Repair ( ) an Individual Sewage Disposal System at: ._..:--- .-- --- �.�"r � i Location-Address or Lot No. r............ - c Owner Address W Installer Address U Type of Building Size Lot.......3_............ ...Sq. feet Dwelling—No. of Bedrooms...............3...............__......Expansion Attic ( ) Garbage Grinder ( ) pa, Other—Type of Building ............................ No. of persons__---__-_----_-------__.___. Showers ( ) — Cafeteria ( ) a' Other fixtures„ -----•-------------------------•-------------- , W Design Flow....................�.a`�.................gallons per person per day. Total daily flow.._..........................�''� ....gallons. 1:4 Septic Tank—Liquid capacity QQ .gallons Length................ Width................ Diameter................ Depth................ Disposal Trench—No..................... Width_............_.......Total Length.................... Total leaching area....................sq. ft. Seepage Pit No.__--------.__-_-___. Diameter------�.._..... Depth below inlet........ '....... Total leaching area.. ...sq. ft. Z Other Distribution box ( Dosing tank ( ) Percolation Test Results Performed b ______Uoyiz___.._ _ _l >._L,: :_ a....... Date......... .._t........................... aTest Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water--__-__--____-------___. Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water---______---_--.._..__-. D Description of Soil-------------- '............... ( S 1( w -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Z. 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. / ! y,� Signed ........ :..... . ............. ..........=--=�------------. . .. Application Approved By p...../...�`�{.L.../ ls� , '- lhi '�f � r-"fi- - 1-';/Date /l , Application Disapproved for the following reason`---------------- -------------------- --------------.......------------................................................ ---. -- ......................-----... s --......._------------------------------------_---------...----------'--......-'---..................................----------'---.....----------.. -............................. ...............................— — �-- -------. -..�• �--: `Date Permit No. .......r. .:... ........................ Issued .�� �I ! /.--...� ----------------------- Dare f ' THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Aof .................................. ".......................................... Certtf rate of Compliance THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed or Repaired ( i by ...................... .................................... ........ . ... ................................ ...-- .......------....--------...---........------.---------- ...........------.------- -- -- •)) Installer at -- ...1.'t:......... 1.1 1/A C.., C:Q - j .. ...'--------------------------------------------------------------------------------------------- has been installed in accordance with the provisions of TITLE'5�of--The S,6te n ironmental Code as described in < �•�° � the THEcISSUANCE1SOF THIS CERTIFICATE SHALL NOT BE CONSTRU� - dated --------1T.E--.. ..�........... E l?P 1? A,� ED`AS A GUAR TE T AT THE SYSTEM WILL FUNCTION SATISFACC Y. DATE.......-` -------Y--"------- � :.... Inspecto -... 6% u � THE COMMONWEALTH OF MASSACHUSETTS ... . BOARD OF HEALTH_ ^� f l .,,�;� oF.. �....� ?- ,�L. ..:. ............................. 1 No...{..............z..... . FEE.. ..................... Disposal Vorkii T11nitr ion antic Permissionis hereby granted......................................................................................................................................... to Construct (�or Reppair ( I ) an Individual Sewage Disposal System kJAL Street i ` P, f' as shown on the application for Disposal Works Construction P � 't No..:____-.__.Cr`=.. ted..____� . ...� .............. •--------- s'---- ------- -- .................... --•--••---- DATE------ a�f' ................................................ Board of Health FORM 1255 HOBBS & WARREN. INC., PUBLISHERS r t 41 BOARD OF HEALTH TOWN OF BARNSTABLE Zpplitation-ftlVell CootruttionPermit Application is hereby made for a permit to Construct ( ), Alter ( ), or Repair ( anv individual Well at: -------------------------------------- -------------- Location — Address Assessors Map and Parcel CA A+A Owner Address ------------------- Installer — Driller Address Type of Building Dwelling--------------------------------------------------- Other - Type of Building-------------------------------- No. of Persons-------------------------------------------------- s/ 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. Signed � ' - / �i date 47 Application Approved By- ----------_�'`!'�� -- — � • date Application Disapproved for the following reasons:----------------------------------------------------------------------------------------------------------- --------------------------------------------------------------------------------------------------------------------- ---------------- — date Permit No. - "� `� ----- Issued- date BOARD OF HEALTH TOWN OF BARNSTABLE Certificate ®f Compliance THIS IS TQ CERTIFY, That the Indi idual Well Constructed ( ), Altered ( ), or Repaired ( ) by-----— �� --------------------------------------------------------------------------------------- /� / L�Installer , � ) r� d�, at----AD —` - /_ f U _(-- �1_�-------- (!v!—-- 2 1" 1�4 ,- -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. ^r-r-;� Dated THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE- - -- - - - -- -- ---- --- - Inspector--------------------------------------—---------------------- - No. ''=- 7 ,`" Fee-0-5- �'-�--- BOARD OF HEALTH r TOWN OF BARNSTABLE Application-jorlVellConstruction j)ermit Application'.is:hereby made for a permit to Construct ( ), Alter ( ), or Repair ( ran individual Well at: Location — Address Assessors Map and Parcel _---— — -- 14 �C W., �i +1� ¢ 'Owner Address tr — — — - -------------------- Installer — Driller Address Type of Building Dwelling--------------------------------------------------------------------- Other - Type of Building------------------------------------- No. of Persons-------------------------------------------------------- TYPe°of Well----------�-.11---------w�'-k - - Capacity- - Purposeof 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 aCertificate of Compliance has been issued by the Board of Health. Signed-1 ------ '�-- � date ApplicationApproved By— ------ date ------------ ------------------------�------ date Application 'Disapproved for the following reasons:—-----________________________—---___-------_------_—-----_----_---—__-__________________ t ------------------------------------------------------------- date Permit No. - `w- -- Issued-----------"'�------ �— `- — -- - - -------------- date r BOARD OF HEALTH TOWN OF BARNSTABLE Certificate ®f Compliance THIS IS O CERTIFY, That the Individual Well Constructed (- ), Altered ( ), or Repaired ( ) by--— � - -1�-'—c -�I/171 ------------------------------------------------------------------------------------------------------------------------- Installer e4 —v` ---L__—= 5:;o� — _W—------ 614fAS 11q4/t-----��4__--------------- 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. Ve--I�--lr !_ 7bated-�---�-93 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 Yell Con5tructionVermit . .� No. - -------------------�! / Fee-------------- -�� Permission is hereby granted--------- La� L_-----7------------ �ti ------------------------------------------------------ to Construct (P, Alter ( ), or Repair ( ) an Indivi ual Well at: No.. - --�-�- - ` - ��— �D s-� -- ---------------------------------------------------------------------------------------------------- Street as shown on the application for a Well Construction Permit Dated------- 9�--- ---------------------------------------------- -1----------- ---- Board of Health DATE------ ------------------------------------- . . r i � � �0 /� � oeool oll COO IJ .. �- 1 Fl M p �\ rRO�SC� a�jt; ur ;1 rop o P(jFR SULLIVAN Plo. 29733 . z d .on 0 �,. PjZppooe '1 A. WELL CAT104 �C��lf--Cl2M 5 tit `rO 04,T-. PEA Q o lJ Rom. W114 TV& Town OF TAAZI,5, Department of Environmental Management/Division of Water Resources £ WATER WELL COMPLETION REPORT WELL LOCATION GEOGRAPHIC DESCRIPTION L 42 /A/ Address � '�� N S E W. of (feet) (circle) City/Town ni v `$ 7 Well owner r y -Ar 1 9- (road) Address N S E W Of (mi.in tenths) (circle) Board of Health permit: yes [� no E] intersect. w/ (road) WELL USE � WELL DATA Domestic © Public❑ Industrial ❑ Total well depth ft. Monitoring❑ Other Depth to bedrock ft. �, Water-bearing rock/unconsolidated material. Method drilled�� r —r— CASING 'h� g Description Date drilled Water-bearing zones: Type P,�3�� � From `21 To �' , 2) From To Length YP ft. Dia(.I.D.)—Y—In.. 3) From To Length into bedrock ft. Gravel pack well: dia. Protective well seal: gf X-.$ Screen: dia. Grout-0 Other Slot# Id length-,?--from��toy PUMP TEST ,,rs Static water level below land surface ft. Date .fir /S r cT Drawdown k- :? ft. after pumping hr. min. at gpm How measured Recovery ft. after —hr.—min. - 0 LOG of FORMATIONS COMMENTS Materials From To 0 Driller Mass. Reegiisstrationn# / L� � r Firm A" N /✓ / �1�� v C/Q Address �D�p / y t 5 City/Town 15h^ r c. & - Si nature of superwsmg reglsrered well driller Please print firmly BOARD OF HEALTH, COPY Log`Numbe`r: Bottle # B28C Date: May*21, 1993 sa BARNSTABLE COUNTY HEALTH AND ENVIRONMENTAL DEPARTMENT 7 � SUPERIOR COURT HOUSE 0 BARNSTABLE, MASSACHUSETTS 02630 J 0 0 MAss DRINKING WATER LABORATORY ANALYSIS PHONE:362-26n Ext. 337 Client: Tartan Inc Collector: C Stiefel Mailing Address: P 0 Box 1198 Affiliation: BCHED West Chatham MA 02669-1198Time & Date of Collection: 5/17/93 2:25 p.m. Telephone: Type of Supply: well Sample Location: Lot 14 Percival Lane Well Depth: West Barnstable MA Date of Analysis: 5/17/93 3:00 p.m. PARAMETER SAMPLE RESULT RECOMMENDED LIMITS Total Coliform Bacteria/100 ml 0 0 H 6.0 Conductivity (micromhos/cm) 65, 500.0 Iron ( m) <.1 0.3 Nitrate-Nitrogen ( m) <.1 10.0 Sodium ( m) 8 20.0 Copper (ppm) 0.1 1.3 I . XXXX Water sample meets the recommended limits for drinking of all above tested parameters. II . Based only on results of the parameters tested for, this sample, the water is suitable for drinking but may present the problems checked below: A. Water sample has higher than average levels of Nitrate. Future monitoring is recommended (2-3 times per year) to establish any upward trends. B. The low pH of the water may shorten the useful life of the house's plumbing. C. Water may~present aesthetic problems (taste, odor, staining) 'due to D. Water sample has high levels of sodium: Persons on low sodium diets should consult their doctor. III. Due to one or more of the reasons checked below, this water sample exceeds the recommended maximum contamination level for drinking water: A. High Bacteria B. High- Nitrates REMARKS: CC: BOH CC: 1 /7/8!� Gaboikat DirectD_r` Explanation of Test Results Total Coliform Bacteria Coliform bacteria are an indicator of the sanitary quality of a water supply. Water supplies may been?-n contaminated from malfunctioning septic systems, cesspools and surface runoff. A total Coliform Count 4 z^r�, indicates that your water supply is safe and approved for human consumption. A total Coliform count of.greater than, zero is most often the result of accidental ontnr-inatior. ;if the sample bottle through improper sampling mrhn's. F,,r this reason. it would be advisable retest an`. %veil u aver thai is ;tot approved. pH pH is the measure of acidity oralkalinity of the N ater.. On tht:p 'scale, the number 7 is neutral• less than " is acidic and more than _ is alkaline. The pH of water on Cape Cod tends to be acidic in the range of 5.0 to 6.5. Conductivity Conductivity is a measure of the dissolved salts in s;tlutinn. Amounts in excess of S00 micromhosicm are generally considered`unacceptable and may have a laxative (,frect upon users. Iron The presence of iron in water in concentration of .3 p,;-n or greater may: give the water a bittersweet astrineent taste. cause an unpleasant odor, often gives the water a hro,.:nish color and cause staining of laundrN and porcelain. The average concentration of iron in Cape Cod's -,eater is .2 - .6 ppm. Although the presence of iron in water may cause the problems listed above, it is not considere;; deleterious to health.' Iron may be removed by use of an iron removal system. Nitrate-nitrogen The MassachusCtts Drinking Water Regulations hsvc set a maximum contaminant level, for nitrates at 10 ppm. Excessive concentrations may cause methemoglobinentia fan infant disease) and have been suggested to form potentially carcinogenic nitrosamines. Contamination sources include fertilizers. cesspools and industrial wastes. Copper Due to the acidic nature of the water.on Cape Cod. copper tends to leach from pipes. This normally does not present a health hazard; however. concentrations in excess of I.0 ppm may cause a metallic taste and/or a bluish-green stain on porcelain fixtures. Sodium A concentration of sodium over 20 ppm is only of c-cincern r: people who are on a loci, sodium diet. If the water supple has more than 20 ppm sodium. it is up to the ne )ple who are on such a diet to find another source of drinking water or contact their doctor to determine if consumine the %wafer is advisable. Concentrations exceeding SO ppm ind::.:ate that there may be ocean water or road salr-J un(-.ff waver eettine into the well. - BARNSTABLE COUNTY HEALTH AND ENVIRONMENTAL DEPARTMENT LABORATORY REPORT VOLATILE ORGANIC CHEMICAL ANALYTICAL RESULTS Client: TARTAN INC Collection Date: 05/17/93 Mailing Address:P 0 BOX 1198 Date of Analysis :05/20/93 WEST CHATHAM MA 02669 Type of Supply: WELL Well Depth (FT) : Not Given Telephone: Sample Location:14 PERCIVAL LANE LAT. (DDMMSS) : Not Given BARNSTABLE LONG. (DDMMSS) : Not Given Collector: C STIEFEL Map/Parcel : Affiliation: BCHD Analytical Method: 502. 1=1 , 502. 2=2 , 503. 1=3 , 504=4 , 524 .1=5, 524 . 2=6 , 502 .1/503=7 --------------------------------------------------------------------- Contaminants Anal . Result MCL Detection Detected Meth. ug/l ug/1 Limits (ug/1) --------------------------------------------------------------------- Chloroform 2 1 .0 0. 5 Only those compounds listed above were detected. Attached is a list of compounds for which this sample was analyzed. NOTE: Contaminant levels equal to or exceeding the Detection Limits are reported. MCL means Maximum Contaminant Level for EPA-regulated compounds . (ug/1 = micrograms per liter = Parts Per Billion) The Environmental Protection Agency has set Maximum Contaminant Levels (MCL) for the following compounds . This sample compares as follows : COMPOUND MCL (in PPB) Benzene 5.0 * level not exceeded * Carbon Tetrachloride 5. 0 * level not exceeded * 1 , 2-Dichloroethane 5.0 * level not exceeded * 1 , 1-Dichloroethene 7 . 0 * level not exceeded * 1 , 4-Dichlorobenzene 75 * level not exceeded * 1 , 1 , 1-Trichloroethane 200 * level not exceeded * Trichloroethene 5.0 * level not exceeded * Vinyl Chloride 2 .0 * level not exceeded * Comments or additional compounds found: + Thomas F. Bourne, Laboratory Director I OF Na UA�Ac�c `GRlrjn�• :'PAIL-(. FLOW .S 5�110 TA� - �-- Dl�Fo5A1 P1T :1Z2 sroN S `fiLArJ o►s BAGk �l�rz� - 51'D c WALL A>z l�� 5►~X 2.p.. 2�l � ?OTOM � 77g.Sr... l-'°T 14' -78 TOTAL-D�161J L (- F�Li VAl._.. D ZIVE 1 70FAL DA I Ly rto V 3xAW o z L i A. °� PETER i SULLIVAN �. N0. 29733 H � Q I FSSIONAL YGa� 1 j r `�l - ---- --- �� TF c 98 ; 1-DA+nn P.v .C• 1 S t5d. loco rub' 2 d" b�ST v : i u GQ(. iuil• C)Z ; Pc�sra� wv +u . iu�. 5 rIc 9+8 �-� $ox s� z: �+ TANe- gel C... ,• A �' S(_ 4�xlSo �l 5 ' OOLD� a� WMNFv. f Ai L 5;�zucr��Es sir -- 11III 5 . .. MOZ5:TUAh1. 4..� Alp ill tit, l� �ZorJ 5 Quo 5/i S C !Fr Pw1 �MN ! � �IELoPC-7j '�vF►t�- ' I �— 1z o sGA LoC. TIOtiI__II "`�. B421� STA-BI u UJTt=IZ; } I � C E 'TI Fy �kr TEE 'D w I4-LJ!J6 i sac N NDz coMPc S :wIT� 5►vEU J��, L,a,7 d "t 1�- lv� or• 13 A �5 ort:o ,ultl{1. . T�I� rLr�o� t -Ait l , �f� S Cis, ( 413 i'Ti T'PrJf=�`florJdl_ Ldu'� `>ue.V;^yc>�; ! 115 R 1�� IS NOT" Q�r-D oN AIJ I STevti�E 1" Su2,/c-:y. . AND rNe om&E 440u S( fL�/ILL'a MAIL , I _ dPPL.Ic;W1 : dr L , 'u1 4 r � , , - , , , :r , •9 T , 10, I t.13 Thy , TA f4u-- I i , t ID - - .. yFv PETER LA SULLIVAN iU No. 29733 "� jAr Y1 t , r Jj � � •_ l 3'-• . _ �. .., gyp/ 1` f IZA. j Ltrv• 11' 0: `C N CO� o i2vt5 TOWn or TAB, i aA--rED ►z has �C 2A-rA __ __ __...._._...._.._.._._._._ ....__... .. �A�13AC�E 'GJ�IiJr�EK.' :PAIL co. sE �c TAa v Dl1Po5A(�. PIT / � laoo SAL. /2 sT�N SEE `fiLA�1 0� BAck �IE2� 51 D c-v�JA L_L_ A I'gg 0 ?OTOM iU-79 T L 16LJ l"bZC-1 QAL— Drzi\)P ' CTAL. VA'LLY. may, {33D r : . T-E cvc.A-noN_ eA-rt : (''�� 3�� :ozlLMZ V/E6r sAv-1 z,�A?,Lr tF... N`CWFZH OF 41 PETER :. SULLIVAN l No. 29733 ti �cjSTER� FSS�OfltA L I loco i �rST u CI Z GAL P��ra� tug. ►uv : iuV. 5Eprlc `t►8 TA Hoc . . GAL' 67 NS �t Ka �a T eA IL OL ALL 5r ucr�zES sir . CELZFiF ED Pt,,T F�A --------------- �/El ypt 'P2a�I Lam-- _ r 2N ST/++L3LE 1 OG-TIC*Q G5,e4LE-'. d-L DATE— y r tv� rz.; 4 . 7 I r� o PLAIN c R�lCc s�lnw N NUZEDN co/VAPLY S. WIT14 -OAIE S�vE�iJ� L,-:"7 PEt�, . - `Ivy!! I oi✓ 3Ar2�g�� 15 orl o w�tt{I T�kF- or> I I, 4 3 � I .. : . : �'Y�11=•t=`f IvrJd►_ �du r� 5ue.��;~yc>�; ! IS �� A�� oN AN ► ST�vti�Ei" Suva/ey...A►JD �LI . :�FF5E1"S SL�ouiaa +J �� N E=ec, To GSTQ'BUSF� 'Plzo�erzT y la t! 5 f rz i L n cA i I :.. _ APPLLc;W r— t 1i d TAP-r -w l plc_ Lr I rl'Q-Or T t T / 100 , r y I / 1 t V i �( r 9p 1r I-, Dw' t �Pf TER o .;SULLIVAN -t 7 No.Z733 O ci @ ONA L CAc' T 1 1 S ._r_{.. , WE �CATt44 �o+� rt_ _ Ferns -o B4/IdST PLQ U o iJ RLr_ TOW n or W k1 PPLICATION FOR PERCOLATION TEST AND OBSERVATION PITS LOCATION ZLo 7' NO* VILLAGE 5'7 , ±A,I VSTi,WL, DAT �-Ag'YG__ APPLICANT FEE ADDRESS /7//fiN S T �/��in6Z/i/� ' TELEPHONE NO.39?-Zz�/ (Non-refundable) ENGINEER wit" G, TELEPHONE NO. '5 46 4411 DATE SCHEDULED — (Appli nt' s signatureV ASSESSOR'S MAP & LOT NO: SOIL LOG SUB-DIVISION NAME UU&Fe ES t4P-6SSlNC% DATE TIME /0,'30 AM EXPANSION AREA: YES NO� _ 170YLE GtiCYINEGQNG ENGINEER:N /� TOWN WATER'.-' ,'PRIVATE WELL I- MGk N BOARD OF HEALTH 0O5 EXCAVATOR SKETCH: (Street name,etc. ,dimensions of lot, exact location of test holes and percolation tests, locate wetlands in proximity to test holes) NOTES: B6 ,' PR'r� Jw� 00 ti Q� h 83 PERCOLATION RATE: 3 MIN /IN TEST HOLE NO: ELEVATION: TEST HOLE NO: ELEVATION: s 1 -rOF AND 5UE5501 L 1 2 c 2 3 4 4 5 5 >>�4�-- 6 , °, SAND 6 7 WIC 7 8 IDOL DC-1�S 8 9 9 10 10 12 p , 12 13 NC) VJA'rC- 13 14 STD 14 15 15 16 16 SUITABLE FOR SUB-SURFACE SEWAGE: LEACHING FIELD LEACHING PITS ✓ LEACHING TRENCHES UNSUITABLE FOR SUB-SURFACE SEWAGE. REASONS: NOTE: ENGINEERING PLANS MUST SHOW NUMBER ASSIGNED .ON PERC TEST APPLICATION ORIGINAL: COMPLETED IN ENTIRETY BY P. E. AND RETURNED TO BOARD OF HEALTH COPY: RETAINED BY APPLICANT m ry Cr} 35 � Co . t�n:� Fi�•i S'�i'EA 22�; i i /t". O 6AS G AAr��� C7 rn v Z m co r(-Ay A?Pf-o)c rl 1 a00M p j r !I i7.M1 i i /6 ' 6 4 PZOPOSIED pL Al�J o � rn c-� Li 12 C7L SNuwc� ix�.lz2. �n1aL+ L3 AT"40 _ �C i�iZJ Z /S /vCw Masi BIZ - - nJ --- - ----- - i C.-L.Ci S E i �\0 - S� �, unJQ� .✓Ar..L. 6o PC--lz DV- 4/--tR if'AbLr f� 0- PLA�v r' X &I ; A r2,AlJ 0 m cy _ a dcw� &CN.Z2 WALL ILI L]•11 H /®T �x " iav(, L.► N�- INr SNF� n�r95; ►L S P 4CF (3c ILOJr't Ii 4 4 �j Il\'iJEC- LJ#9LL { W�7GH OALL CX r S'i i /v C rL J0 P4-,9 iV 2-.n-)►7 1=�cc� - L