HomeMy WebLinkAbout0094 PERCIVAL DRIVE - Health 94 Percival Drive
W. Barnstable P
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-\ COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS .
DEPARTMENT.OF ENVIRONMENTAL PROTECTION
MAP
PARCEL : 001 02�
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 9.4 Percival, Drive
W. Barnstable, MA RECEIVED
Owner's Name: Francis & Marilyn De'coste
Owner's Address:
APR..1 3 20,04
Date of Inspection: /=d C) 1-f TOWN OF BARNSTABLE
HEALTH DEPT.
Name of Inspector:(please print) W111 i am _ •Robinson Sr. -
CompanyName: William E. Robinson Septic Service
Mailing Address: P O Box 1089
Centerville, MA -
Telephone Number:— (508,1 7 7 5—8 7 7 b
CERTIFICATION STATEMENT
I certify that 1 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 15340 of Title 5(310 CMR 15.000). The system:
,C, Passes ,
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: i- %�✓/ , n Date:
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Healttror
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 ent to the.buyer,if applicable,and the approving
authority.
Notes and Comments
""This report only describes conditions at the time of inspection and under the conditions of use at that
time.This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page 1
Page 2 of l 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 94 Percival Drive
W. Barnstable, MA
Owner: Francis & Marilyn Decoste.
Date or inspection: .
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. Syst Passes:
I have not found any information which indicates that any of the failure criteria described in 310 CM;
15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated.below.
Comments:
,77777
B. Syst Conditionally Passes:
On or more system components as described in the"Conditional Pass
" e s section need to be replaced or
re aired. .p e system,upon completion of the replacement or repair,as approved by the Board of Health,will:pass.
Answer yes, o or not determined(Y,N,ND)in the explain. for the followi..ng statements.if`bat determined"please
The sep is tank is metal and over 20 years old"or the septic tank(whether metal or not)is structurally
unsound,ckxhi its substantial infiltration or exfiltration or tank failure is imminent_System will pass inspection if the
existing tank i replaced with a complying septic tank as approved by the Board of Health.
•A metal septi tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that a tank is less than 20 years oid is available:
ND explain:
Obsery ion 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 Bo d of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The s tern required pumping more than 4 times a year due to broken or obstiwed pipe(s).The system will
pass inspectio if(with approval of the Board of Health):
broken pipe(s)are replaced
obswction is removed27
5 1
ND explain:
i
Page 3ofiI
OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 94 Percival Drive
W. Barsntab e, MA
Owner: Francis A Marilyn Decoste
Date of Inspection: . L/—/
C. F. rther Evaluation is Required by the Board of Health:
nditions-exist which require fiuther evaluation by the Board of Health in order to determine if the system
is failin to protect public health,safety or the environment.
1. S stem will pass unless Board of Health determines in accordance with 310 CMR.15.303(1)(b)that the
sy tem is not functioning in a manner which will protect public health,safety,and the environment:.
Cesspool or privy is within 50 feet of a surface water
Cesspool or.privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
_ e system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surf cc water supply or tributary to a surface water supply.
_ The system has a septic tank and SAS and the SAS is within a Zone i of a public water supply.
The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more frond a
rivate water supply well•• Method used to determine distance
This system passes if the welt water analysis,performed at a DEP certified laboratory,for coliform
acteria and volatile organic compounds indicates that the well is free from pollution from that facility and
e presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
f ilure criteria are triggered.A copy of the analysis must be attached to this form.
3. O her:
3
Page 4ofII
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY,ASSESSMENTS
I
SUBSURFACE SEWAGE`DISPOSAL SYSTEM INSPECTION FORM._
PART A
CERTIFICATION(continued). ... .
Property Address: 94 Percival Drive -
i
W. Barnstable, MA
Owner: Francis & Marilyn Decoste
Date of Inspection:. 4g,—/-0 vl
D. Sy lem Failure Criteria applicable to all systems:
You t indicate`yes".or"no"to each of the following for all inspections:
Yes N � .. ,
of sewage into facility or stem component due to overloaded
Backup, o ed or clogged SAS or cesspool. f
Discharge-or ponding of effluent 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'/:day ow
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.
y portion of cesspool or privy is within 100,feet of a surface water supply or tributary to a surface
water supply.
y portion of.a cesspool ouprivy is within a Zone I of a.public well.
y portion of a cesspool or privy is within 56 feet of a private water supply well'
y portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private%%-AW
supply well with no acceptable water quality analysis.]This system passes if the well water analysis,
performed al a DEP certified laboratory,for coliform bacteria and Volatile organic compounds
Indicates that the well is free.from pollution from that facility and the presence of ammonla
nitrogen and nitrate nitrogen is equal to or less than S ppm,provided that no other failurc criteria
are triggered.A copy of the analysis must be attached to this form.]
( es/No)The system rails.1 have determined that one or more of.the above failure criteria exist as
described in 310 CMR 15303,therefore the system fails.The system owner should contact the Board of
Health to determine what will be necessary totorrect the failure.
E. L ge Systems:
To be onsidered a large system the system must serve a facility with a design now of 10,000 gpd to 15,000
gPd•
You ust indicate either"yes"or"no"to each of the following:
(Th following criteria apply to large systems in addition to the criteria above)
y 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 11 of a public water supply well
lifyu have answered"yes"to any question in Section E the system is crosidered a significant threat,or answered
yes"in Section D above the large system has failed.The mAmer err operator of any large system considered a
sigt ificant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
IS..' 04.The system owner should contact the appropriate regional office of the Department.
4
page 5 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART.B
CHECKLIST
Property Address: 94 Percival Drive
W.-Barnstable, MA
Owner. Francis & Marilyn Decoste
Date of Inspection: -��/�U
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 T.
Were as built plans of the system obtained and examined?(If they were not available note as N/A)
_ Was the facility or dwelling inspected for signs of sewage back up?
_ Was the site inspected for signs of break out?
_ Were all system components,excluding the SAS;located on site?
_ _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition
of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum?
` ,I
11 Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:, .
Yes no
_ 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 CIAR 15.302(3)(b))
5
Page 6 of 11
OFFICIAL INSPECTION FORM-.NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL"SYSTEM INSPECTION FORM
PART C.
SYSTEM INFORMATION
Property Address: 94 Percival Drive
W. Barnstable; MA
Owner.Francis & Marilyn. Decoste
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design):. 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15103(for example: 110 gpd x#of bedrooms): 9 G 6
Number of current residents:
Does residence have a garbage grinder(yes or no)
Is laundry on a separate sewage system(yes or no) .k) [if yes separate inspection required)
Laundry system inspected(yes or no):h o
Seasonal use:(yes or no):A(/C,)
Water meter readings,if available last 2 ears usa e ' d : 'N/A
( Y g (gP ))`.
Sump pump(yes or no):_Z—& ,.
Last date of occupancy:
COM RCIAL/INDUSTRIAL
Type of tabiishment:
Design fl iw(based on 310 CMR 15.203): tend
Basis of 4 csign flow(seats/persons/sgft,etc.): :.
Grease tr p present(yes or no):_
inclustriaq waste holding tank present(yes or no):._
Non•san' waste discharged to the Title 5 system(yes or no):
Water . ter readings,if available:
Last dat of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: di 1
Was system pumped as parrof the inspection.(yes or no):_
If yes,volume pumped:_gallons-=How was quantity pumped determined?
Reason f r pumping:
TYP OF SYSTEM
OF
tank,distribution box,soil absorptivn.system
_Single cesspool
Overflow cesspool
Privy
_Shared system(yes or no)(if yes,attach previous inspection records,if any).
_Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
_Tight tank _Attach a copy of the DEP approval
Other(describe):
Approximate age of all components,date installed(if known)and source of information:
)G.9 Lf'
Were sewage odors detected when arriving at the site(yes or no):—0
6
Page 7 of 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 94 Percival Drive
W. Barnstable, MA
Owner: Francis & . Mar J yn Decoste
Date of Inspection: 0 '—
BUIL G SEWER(locate on site plan)
Depth be w grade: _
Materials of construction:_cast iron 40 PVC other(explain):
Distance om private water supply well or suction line:
Comme is(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK: (locate of site plan)
)
Depth below grade: �! /
Material of construction: ✓co.�crete metal fiberglass_polyethylene
If tank is metal list age:_ [sage confumed-by a Certificate of Com liance
certificate) P (yes or no):_(attach a copy of
Dimensions: L la
Sludge depth:_ I/—
Distance from top of sludge to bottom of outlet tee or baffle: Qr
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of udet tee or baffle:
How were dimensions detcrmincd: (, �
Comments(on pumping recommendations,inlet and outlet tee or baffle conditicn,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.): ,
GREASE P:_(locate on,site plan)
Depth below ade:_
Material of co structiow_concrete metal fiberglass_polyethylene_other
(explain): _
Dimensions:
Scum thickness
Distance from t p of scum top Hof outlet tee or.baffle:
Distance from -ottom of scum to bottom of outlet tee or baffle:
Date of last pu ping:
Comments(o pumping recommendations,inlet and outlet ice or baffle condition,structural integrity,liquid levels
as related to o let invert,evidence of leakage,etc.):
7
Page 8 of 11
OFFICIAL INSPECTION FORM,-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:94 Percival Drive
W. Barnstab e, MA
Owner: Francis & Marilyn Decoste
Date of Inspection:_ -1-1- O
TIGHT or H LDING TANK: (tank must be pumped at time of inspection)(locate on site plan)
Dcpth below gr de:
Material of cons ruction: concrete metal fiberglass Dolyethylene other(explain):.
Dimensions: _
Capacity.. allons
Design Flow: allons/day
Alarm present s or no):
Alarm level: Alarm in working order(yes or no):
Date of last pum ing:
Comments(con ition of alarm and float switches,.etc.):
DISTRIBUTION BOX: /(ifresent must be opened)(locate on site plan)
Depth of liquid level above outict invert:
Comments(note if box is level and distribution to outicts equal,any evidence of solids carryover,any evidence of
leakage into or out of box,etc.): G
O)
PUMP CHA IDER: (locate on site plan)
Pumps in wor ing order(yes or no):
Alarms in aor ing order(yes or no):
Commcnts(no c condition of pump chambcr,condition of pumps and appurtenances,etc.):
j
8
Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 94 Percival Drive
W. Barnstable, MA
Owner: Francis & Maril n Decoste
Dade of Inspection: A;�—I o
SOILABSORPTION SYSTEM(SAS):2(10cate on site plan,excavation not required)
If SAS not located explain why:
Type 1.
leaching pits,number:,
leaching chambers,number:
leaching galleries,number:
leaching trenches,number,length:
leaching fields,number,dimensions:
overflow cesspool,number:
innovative/alternative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,
etc.):
CESSP OLS: (cesspool must be pumped as part of inspectionxlocate on site plan)
Number a d configuration:
Depth—to of liquid to inlet invert:
Depth of s lids layer:
Depth of sc im layer:
Dimensiory of cesspool:
Materials o construction:
Indication f groundwater inflow.(yes or no):
Comments note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
PRIVY: (locate on site plan)
Materials f construction:
Dimensio
Depth of s lids:
Comments note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
9
Page 10 of 11
OFFICIAL INSPECTION FORM-.NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 94 Percival Drive
W. Barnstable, MA
Owner: Francisr9 Marilyn Decoste
Date of Inspection: /.. 4_
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a.sketch of the sewage disposal system including ties to-at least two permanent reference landmarks,or
benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building.
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Pagel 1 of 11
OFFICIAL INSPECTION FORM-.NOT FOR VOLUNTARY ASSESSMENTS .
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Prop"Addr ess:94 Percival Drive
W. Barnstable, MA
Owner. Franics & Marilyn Decoste
Date_of Inspection: Ll -!- O LI
STYE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 3 0 feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
/97 s0 S 6 0 2
11
TOWN OF B/ARNSTABLE
LOCATION /p.- �VS-' SEWAGE # 97585
VILLAGE ASSESSOR'S MAP & LOT
INSTALLER'S NAME & PHONE NO..�� �rn I-L -44'��'y
SEPTIC TANK CAPACITY Jf aAJ
LEACHING FACILITY:(type) i7i 41 g spa- (size) /60 ) gay/
NO. OF.BEDROOMS ' 3 PRIVATE WELL OR UBLIC WATER Vi\\
BUILDER OR OWNER 7A01
DATE PERMIT ISSUED:
DATE COMPLIANCE ISS.
VARIANCE GRANTEM Yes No
i
rotv+is r
16011
� 9
15
D
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AP= 'igJ air ��,
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r1'y TOWN OF BARNSTABLE
LOCATION �� l/� ��C;�sA/ fir; SEWAGE #
110 -
VILLAGE ASSESSOR'S MAP & LOT
INSTALLER'S NAME & PHONE NO. L L ` --G'��
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) i7i 4 6✓g 5lc,,w (size) /6,00 qAl
NO. OF BEDROOMS 3 PRIVATE WELL OR PUBLIC WATERC VJ�'\\
T—
BUILDER OR OWNER _7A01
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
t
a R , E
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No.._1.GG. .. 5 Fim.......I.�..�.......
THE COMMONWEALTH OF MASSACHUSETTS
aa it BOARD OF HEALTH
TOWN OF BARNSTABLE
App iratiun for Biupuual Workii Tonutrnriiun Prrutit
Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
System at: 1cy t'
--.......-91- `e.9 �L .......0 =------------------- ---- -----------------,I"-------•----------------•............---
Location-Address _ or Lot No.,�l
!`l(lLr_fl�` flSuC.L lale !�...Y'.. ,
........ •- -...... ................
Owner Address
..... fit.. ._..... . ....... - • ....... �LCiU��---•------•---------------•---...--------------•-•-•--.........------------•-----.......---•---
Installer Address
Q _Type of B ing Size Lot.___. iCo '...Sq. feet
U Dwelling—No. of Bedrooms________________�+_.. ._.__Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building No. of persons____________________________ Showers — Cafeteria
Q' Other fixtures ____________________________
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity/puma.gallons Length_ �6_"_____ Width._5.-j9._.:_ Diameter---:f=..... Depth___ =f..
x Disposal Trench—No_ ____________________ Width..................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No............./----- Diameter-----//r....... Depth below inlet___.._.V......... Total leaching area.. ...sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by----/ _ ................................................ .............
Test Pit No. I...... _..___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........................
-------------------------I.............. .......................................
O Description of Soil 1 IIM!l..... ✓!� = 6 -- '•.�1�✓1 � �
x
U -------------------------------------------- --------- --------------------__...............................................................................................
W
UNature of Repairs or Alterations—Answer when applicable...............................................................................................
..................................................-............................................................................•.........................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not o lace the
system in operation until a Certificate of Compliance issued he board of-healt .
Signed ------- -- ----- --- ..---...... ----- - -- ------- .
/" Date.. -- ---..-
A lication Approved B '-`. .... - ---------------------- --------- -------- .......
PP PP.. Y .-...-.... v �
Dare
Application Disapproved for the following reasons- -------------------------------------------------------------------------------------------------------------------------- ----- ----
--------------------------------------------------I....-- -- -------------- -- ............................................................
--------------
Permit No. �"� 15-
/ --------J iV --------------_ Issued ---.-----------------------------....--------........fe---...
Date
r
No...lr..... 5 FEs................. ........
THE COMMONWEALTH OF"MASSACHUSETTS
�&,
BOARD OF HEALTH
TOWN OF BARNSTABLE
Appliration for Disposal Works Tonstrnrtion rrmit
- Application is hereby made for a Permit to Construct ( y�or Repair ( ) an Individual Sewage Disposal
r
... ..r....Location-Address .... or Lot No. ........................................
............ -. . ....... ...... _ A. -..r
Owner Address...........................................
Installer Address'
Type of Bu>ldin Size Lot.. ..�. �.$_ ...Sq. feet
UI— Garbage GrinderDwel in No. of Bedrooms............... _.....................Expansion Attic ( ) ( )
Other—T e of Building No. of persons............................ Showers — Cafeteria
al Other fixtures ..................................
W Design Flow.............................. .... ._.._.gallons per person per day. Total daily flow....!......................................gallons.
WSeptic Tank—Liquid capacitylr�6a__gallons Length..`G_'__.. Width.. k_.._. Diameter... Depth....'= ..
x Disposal Trench—No. .................... Width............ Total Length.................... Total leaching area....................sq. ft. '
Seepage Pit No.............../-___- Diameter.._..��......... Depth below inlet....... ".._._... Total leaching area..A��=._sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by..../ E! .A� ...................{.. ...:..................... Date../i?n .: uF ?::..........
a Test 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........................
Description of Soil 7.. �r �............., (/
W e
W ........---•-----•------••--•--------------•----...__---------------------------•--...._............___..._.__....._..__.._.....___..............___.._......._......_.............._................... 1
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 n ace Zthe
system in operation until a Certificate of Compliance s been Issued by,/the board of health.
I` Signed . f - - -
V Date
i\ Application Approved By ................. - -_ .................. -----.---- ........ ......Date
Application Disapproved for the following reasons:
-------------------------------------- -- ----------------------------- .............................-------
G
Permit No. .--......1.. v. ....5—-.5.5............. Issued .........................................................Da-.te
- ......
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
�er#tfi>ctt#E of C�oxi<c�li�xx><ce
THIS IS TO CERTIFY,Jlfat the Indd .ual-Se age Disposal System constructed (}�) or Repaired ( )
b ..------- -�- k l �S%fl
C�
Installer
It � ......................................... -- -- ---- ------------------------------------------
has been installed in accordant with the provisions of TITLE 5 of The State Environmental Code as described in
the application for Disposal Works Construction Permit No. .....��y..^.. .. dated ................................................
.,THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE-------- `'1-.- ��''........................................... Inspec •r-± ...... ............. �/
Y
THE COMMONWEALTH OF MASSACHUSETTS
BOARD- OF HEALTH
TOWN OF BARNSTABLE
Disposal Work C_unstrt uan- rrmi
,Vi
Permission is hereby granted '.._.,.. . :-.1 -A....................................................
to Construct (`� or Repair ( ) an Individga S . e Dispos�a'l�l /Sfstem
atNO. ... .... �.. ........... e -... ----- ....................................
Street F
as shown on the application for Disposal Works Construction Permit No.,7��--"J-� Dated......11=17:7-.__�/....
.� ..................................................
Board of Health
DATE.........R: V' L-•� -j....................................... I
FORM 36508 HOBBS&WARREN.INC..PUBLISHERS
Bot er: ' 546101 Date: 09/19/94
Of x, R�
BARNSTABLE COUNTY HEALTH AND ENVIRONMENTAL DEPARTMENT
SUPERIOR COURT HOUSE
O
V BARNSTABLE, MASSACHUSETTS 02630
• e
A SS PHONE:362-2511
LAB 337
Client: ANTIPASTI , PAUL Collector: CHARLOTTE STIEFEL
Mailing 102 STANHOPE RD Affiliation: COUNTY
Address : WAQUOIT - MA 02570
Type of Supply: W
Telephone: Well Depth: 83 FT
Sample Location: 45 PERCIVAL RD Date of Collection: 09/13/94
Town: WEST BARNSTABLE Date of Analysis : 09/13/94
------------
PARAMETER SAMPLE RESULT RECOMMENDED LIMITS
Total Coliform Bacteria/100 mL *INCONCL 0
pH 6 .9
Conductivity (micromhos/cm) 115 500
Iron (ppm) 0 . 4 0. 3 I
Nitrate-Nitrogen (ppm) 0 ,1 10 .0
Sodium (ppm) 15 20.0
Copper (ppm) 0 . 1 1 . 3
BASED ON THE ANALYSES PERFORMED, THE FOLLOWING ADVISORIES ARE GIVEN:
I
* Based on the results of the parameters tested, the water is suitable
for drinking but may present aesthetic problems
(taste, odor, staining) due to iron.
* Results are Inconclusive due to high filterable solids.
. Retest of just the Total Coliform is recommended (no charge to you) .
Please come to Lab for another bottle and. we will instruct you further.
Thomas F. Bourne, Laboratory Director
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CERTIFICATE OF ANALYSIS Page.
Barnstable County Health Laboratory
Report Dated: 11/16/2005
Report Prepared For:
Order No.: G0533726
Pamela McElhinney
94 Percival Drive
W. Barnstable, MA 02668
Laboratory ID#: 0533726-01 Description: Water-Drinking Water
Sample#: 33726 Sampling Location 94 Percival Dr.W.Barnstable,MA- Collected: 11/15/2005
Collected by: P.McElhinne Map 110 Parcel 001-022 Received: 11/15/2005
Routine
ITEM RESULT UNITS RL MCL Method# Tested
LAB: Inorganics
Nitrate as Nitrogen 4.9 mg/L 0.10 10 EPA 300.0 11/15/2005
LAB: Metals
Copper BRL mg/L 0.10 1.3 SM 3111B 11/16/2005
Iron BRL mg/L 0.10 0.3 SM3111B 11/16/2005
Sodium 31 mg/L 1.0 20 SM 311113 11/16/2005
LAB: Microbiology
Total Coliform 0 CFU/100ML 0 0 303 11/15/2005
LAB: Physical Chemistry
Conductance 150 umohs/cm 1.0 EPA 120.1 11/15/2005
pH 6.4 pH-units 0 EPA 150.1 11/15/2005
- - - - o
Sodium level is above the maximum contaminant leveCThose on a low`od um_diet may wish.to.consuIt a.physicianr,_
Approved By: �.rector)
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RL = Reporting Limit
MCL=Maximum Contaminant Level
Superior Court House, PO.Box 427, Barnstable, MA 02630 Ph: 508-375-6605