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Home My WebLink About1055 SERVICE ROAD - Health 1055 SERVICE ROAD WEST BARNSTABLE A = 152 003 001 1 i Town of Barnstable �eftHE'o�� Regulatory Services l J �2_-6 3 3 Thomas F. Geiler,Director •;BAF.Nsane� PUSS. Public Health Division Thomas McKean, Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer & Resigner Certification Form !/ 0 3 `3 Date: �� Sewage Permit# 7' Assessor`s MapTareel /�Z U / Designer: d..,r?�� Installer: Address: -- Address: !'CIS ((X S� On C y'- 1llcilvlwas issued a permit to i stall a date) �v S'� 5�.i^vr'sc�ler} et.cp septic system at 2,r6 1 j based on a design drawn by (address) dated ✓yimt �f ZV-6 Z (desi er) I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank, I certify that the septic system referenced above was installed with major changes (i.e, greater than 1 0' lateral relocation of the SAS or any vertical relocation of any component ofthe:septic.system)but in accordance with State & Local Regulations. Plan revision or certified as-built by designer to follow. • OVA gTr 11 o� �oHN cyG� P. (r aller's Signature) D.OYLE,W No.33589 tST_ p (Des' er's Signature) (Affix D er's Stamp ere) PLEASE RETURN TO BA&NSTABLE PL93LIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-BUILT CARD ARE RECEIVED BY THE BARNSTABLE PL;BI,IC HEALTH DIVISION. THANK YOU. it Q; Health/Septic/Desigrer Certification Form 3-26-04.doc I I ENVIROTECHLABORATORIES,INC. ' MA CERT.NO.:M-MA 063 8Jan Sebastian Dr-Unit#12 Sandwich, MA 02963 908(888-6460) 1-800 339-6450 FAX(908)888-6446 CLIENT: L Wile&Son Wells LOCATION: Lot 3 Hse Lot 1055 ADDRESS: (Larry Nickulas Building) Service Rd W Barnstable MA COLLECTED BY. L Wile&Son Wells SAMPLE DATE: 4/22/2004 SAMPLE TIME. N/A WATER SAMPLE TYPE: New Well DATE RECEIVED: 4/22/2004 LAB►.D. #: 0404423 WELL SPECS.: 120'4"PVC Well 20 GPM 32'to Static RESULTS OF ANALYSIS: Parameters Units Recommended Results Method Date Analyzed Limits Coliform bacteria /100ml 0 0 9222 B 4/22/2004 pH pH units 6.5-8.5 6.08 4500 Ht, ' 4/22/2004 Conductance umhos/cm 500 257 120.1�. 4/22/2004 Nitrate-N mg/L 10.0 2.61 300.0 4/22/2004 Nitrite-N mg/L 1.00 < 0.004 300.0 4/22/2004 Sodium mg/L 20.0 27.0 200.7 4/22/2004 Iron mg/L . 0.3 < 0.1 200.7 4/22/2004 Manganese mg/L 0.05 <0.008 200.7 4/22/2004 Volatile Organics See Report Chloroform ug/L 80 0.9 EPA 524.2 4/29/04 COMMENTS: pH is below recommended limit and may have corrosive characteristics. Sodium level is not a health hazard. t _ , WATER MEETS EPA STANDARDS AND IS SUITABLE FOR DRINKING PURPOSES FOR PARAMETERS TESTED. r r; ND`= None Detected. <=less than >=greater than TNTC=too numerous to count n Date 0 o m R ald J. Sa i Laboratory D ector a Page 1 of 3 R.I. Analytical Specialists in Environmental Services CERTIFICATE OF ANALYSIS Envirotech Laboratories,Inc. Date Received: 04/23/2004 Attn: Mr.Ron Saari Date Reported: 04/30/2004 8 Jan Sebastian Drive P.O.#: Sandwich,MA 02563 Work Order# 0404-05751 DESCRIPTION: LARRY NICKULAS(ONE DR.114 ING WATER SAMPLE) Subject sample(s)has/have been analyzed by our Warwick,R.I.laboratory with the attached results. Reference: All parameters were analyzed by U.S.EPA approved methodologies and all NELAC requirements were met The specific methodologies are listed in the methods column of the Certificate Of Analysis. Data qualifiers(if present)are explained in full at the end of a given samplers analytical results. Certification#: RI-033,MA-RI015,CT-PH-0508,ME-RIO15 NH-253700 A&B,USDA S-41844,NY-11726 If you have any questions regarding this work,or if we may be of further assistance,please contact us. Approved b . PP y' c Data Reporting enc: Chain of Custody 41 Illinois Avenue,Warwick,RI 02888 131 Coolidge Street,Bldg 2,Hudson,MA 01749 Tel:(401)737-8500 Fax:(401)738-1970 Tel:(978)568-0041 Fax:(978)568-0078 Page 2 of 3 R.I.Analytical Laboratories,Inc. CERTIFICATE OF ANALYSIS Envirotech Laboratories,Inc. Date Received 04/23/2004 Approved by. Work Order#: 0404-05751 'Data Korfing Sample# 001 SAMPLE DESCREMON: 0404423 LOT 3 HOUSE LOT 1055 SERVICE ROAD WEST BARNSTABLE SAMPLE TYPE: GRAB SAMPLE DATFJ11ME: 04/222004 SAMPLE DET. DATE PARAMETER RESULTS LIMIT UNITS METHOD ANALYZED ANALYST Volatile Orgaax Compmunis &omodichlaromedme <0.5 0.5 U94 EPA 5242 04/29/2004 AMT Bromoform <0:5 0.5 ugA EPA 5242 04/29t2M AMT Dibmmochlommethane <0.5 0.5 ug/l EPA 5242 04129/2004 AMT Chloroform 0.9 0.5 ug4 EPA 5242 04/29MM AMT 1,2-Dibromodhanc(®13) <0.5 0.5 ug/1 EPA 5242 04/29M04 AMT Benzene <0.5 0.5 ngA EPA 5242 04/29/2004 AMT Carbon Tetrachloride <0-5 0.5 n94 EPA 5242 0429/2004 AMT 1,2-Dichloroethane <0.5 0.5 U94 EPA 5242 04292004 AMT Trichloroethene <0.5 0.5 U94 EPA 5242 04/292004 AMT 1,4-Dichlombenzene <0.5 0.5 ngA EPAS242 04292004 AMT 1,1-Dichloroethane <0.5 0.5 no EPAS242 04292004 AMT I,1,I-Tiichlomethane <0.5 0.5 WA EPA 5242 04292004 AMT Vinyl Chloride <0.5 0.5 no EPA S242 0429f2M AMT Bromobertzene <0.5 0.5 WA EPA 5242 04292004 AMT Bromometharre <0.5 03 094 EPA 5242 04/292004 AMT Chlorobenzene <0.S 0.5 no EPA 5242 04292004 AMT C hlomethane <0.5 OS n94 EPA 5242 04292004 AMT Chloromethane <0.5 0.5 ug/l EPA 5242 04292004 AMT 2-Chlomtohme <05 0.5 WA EPA 5242 04292004 AMT 4-Chlomtoluene <03 0.5 WA EPA 5242 04292004 AMT Dibromomethane <03 0.5 ng/t EPA 524.2 04292004 AMT 1,3-Dichlombeazene <0.5 0.5 U94 EPA 5242 04/292004 AMT 1,2-Dichlorohenzene <0.5 0.5 u94 EPA 5242 0429,7M AMT tra€s-1,2-Dichbroethene <0.5 0.5 ug/l EPA 5242 04/292004 AMT cis-12-Dichloroethene <0.5 0.5 "A EPA 524.2 04292004 AMT Mdhyleoe Chloride <03 0.5 ag/1 EPA 5242 04292004 ANT 1,1-Dich1oroethene <0.5 0.5 ugil EPA 5242 04/292004 ANT 1,1-Dichloroprapene <03 0.5 U94 EPA 5242 04292004 AMT la-Dichloropropane <0.5 0.5 ugA EPA 5242 04292004 AMT 1,3-Dichloropmpanc <0.5 0.5 ug/lEPA 5242 04292004 AMT cis-1,3-Dichloropropene <0.5 0.5 ug/l EPA 5242 04292004 AMT 2,2-Dichioropropane <0-5 0.5 094 EPA 5242 04292004 AMT Ethy$enzene <03 0.5 agA EPA 5242 0429/M AMT Styrene <0.5 0.5 ug/1 EPA 5242 04292004 AMT 1,1,2-Trichbmethane <0.5 0.5 ug/1 EPA 5242 04292004 AMT 1,1,1,2-Tdrachlomdhane <0.5 0.5 ug/1 EPA 5242 0429I2004 AMT 1,1,22Tetrachlorodhane <0.5 0.5 ugA EPA 5242 0429/2004 AMT Tetrachloroethene <0.5 0.5 u9/1 EPA 5242 04292004 AMT 1,2,3-Trichloropropane <0.5 0.5 ug/l EPA 5242 0429I2004 AMT Toluene <0.5 0.5 ug/1 EPA 524.2 04292004 AMT Page 3 of 3 R.I.Analytical Laboratories,Inc. CERTIFICATE OF ANALYSIS Envirotech Laboratories,Inc. Date Received: 04/23/2004 Approved by. • Work Order k 0404-05751 45malANAng ma�ple# 001 SANYPLE DESCRIPTION: 0404423 LOT 3 HOUSE LOT 1055 SERVICE ROAD WEST BARNSTABLE SAMPLE TYPE: GRAB SAMPLE DATFJI'RVIE: 04/22/2004 SAMPLE DET. DATE PARAMETER RESULTS LIMO[T UNITS METHOD ANALYZED ANALYST Xylem <05 0.5 WA EPA 5242 OV 2004 AMT 1,24X o 34MMa{aopene <05 0.5 ug/l EPA 5242 04/29/2004 AMT Brmnmhlommethane <03 0.5 ng/1 EPA 5242 04/29/2004 AMT n-Butylbcu=c <OS 0.5 uvi EPA 5242 m9/2004 AMT Dichkmodifiamoumdme <0.5 0.5 WA EPA 5242 04292004 ANT Uddomflnommdham <OS 0.5 WA EPA 5242 0429rAN AMT Hatchlorobutadienc <0.5 0.5 U94 EPA 5242 04129fAM AMT L4apropylbaurae <0.5 0.5 U94 EPA 5242 0429M M AMT p-bopropyhol— <05 0.5 WA EPA 5242 0429fAM AMT Naphthalene <OS 0.5 WA EPA 5242 04292M AMT n-pmpy%e-me <0-5 0.5 USA EPA 5242 04292004 AMT =4c utylbenzme <0.5 0.5 ug/1 EPA 5242 0429/2004 AMT tat-Butylbeozene <0.5 0.5 WA EPA 5242 04292004 ANT 1,"Trichlombmzene <05 0.5 ug/1 EPA 5242 04292004 AMT 1,2,4-Tdchlambmzwe <0.5 0.5 ug/1 EPA 5242 04292004 AMT 1,2,4-Ttimdhy4beazme <0.5 0.5 U94 EPA S242 04292004 AMT 1,3,5-T <0.5 0.5 ug/l EPA 5242 04292004 AMT Med*4 Tertiary Butyl Ether(MTBE) <1 1 ugll EPA 5242 04292004 AMT n-Hezane <10 10 U94 EPA$242 04292004 AMT SURROGATES RANGE EPA 5242 04292004 AMT 4 99 80-120% EPA 5242 04292004 AMT 1,2-Dich1ombcn=a-& 107 80-120% EPA 5242 04292004 AMT Massachusetts Department of Environmental Management 128152 Office of Water Resources c T OR PRINT ONLY+ Well Completion Report. 1.WELL LOCATION x GPS(OPTIONAL)- gkLATITUDIr,` �. 0N,ITi3 7E 'a Address at Well Locationri/� /19 S J Alle' , w S Property Owner• Subdivision Name: Ch 12 Mailing Address: d ® " 30.7 Qn t v �City/Town: 2/i.�i /�j ;CitylTown: Assessors Map Assessors Lot# NOTE: Assessors Map and Lot# mandatory If no street addres 'ava bled 1342 Board of Health permit obtained: Yes Not Required ❑ Permit NumberWIV- aDateJssued" `~ 2:WORK PERFORMED., = -° 3.;PROPOSED USE a0114 LLING METIiflQ El ,New Well ❑ Abandon El Domestic ❑.Irrigation ❑ Cable ❑ Auger .. ❑ Deepen ❑ Recondition El Monitoring ❑ Municipal ❑ Air HammerQ Direct Push ElReplace El Other ❑ Industrial El Other ElMud'866��-,❑ Other 5.WELL LOG oC Unconsolidated Consolidated 6;rtS1!'ESJCE7CFi°(o per nentla ,arksw;maistances) W Permeability E2to e - From (ft) To (ft) > High Low `A15 m Other Rock Type r .., ol U �` U b 6v A. 7;WELL CONSTRUCTION, 8;£CASINGr 1 . n Total Depth Drilled J210 From (ft) To(ft) -Casing Type and Material Size O.D.v(In).. WeIVS6M Type .. Date Drilling C mplete� 4f - -�. r- -a _ ',k�`. From (ft) To (ft) Slot Size Screen14pe and M!!42al ,rScrpen Diameter 10. FILTER P/ CK:I GRONT °ABANDONMENT MATERIAL ° rq,� I11�=ADDM AL=1NELt-'INFORMATION= ' _ . . - n �„ Developed? ❑ Yes CrNo From (ft) To (ft) Material Depqdption�,:��u Purpose Fracture �� 1 .a Enhancement? Yes L`f No °mx Method Iw L Disinfected? L"J Yes ❑ No 12.WELL TEST-DATA{PRODUCTION WEI<LS) Iy N- `13:`STATIC WA►TER;LEVELYJALL�A L1S). v�.R _ Yield, 1i Pumped Drawdown to Time Recovery to Depth Below Date Method GPM hrs' min Ft. BGS hrs&min R. BGS D to Measured Ground Surface �, /ow I I �y 2laq v - t � ` A 1A7{ C} PA�Yi4.PERMANENT PUMP FAVAILASL t Pump Description Horsepower Pump Intake Depth n (ft) Nominal Pump Capacity (gpm) 16.COMMENTS 17. WELL t3RILLER'S STATEMENT._a$ This well was drilled and/or abandoned under my supervision, according to applicable rules and regulations, and this repdrt is complete and co rest to the best of my knowledge. Driller: ` Supervising Driller Signature- �'" fif Registration #: ter,. Firm: Date: Rig Permit#: NOTE: Well Completion Reports must be filed by the registered well driller within 30 days of well completion. .. -BOARD OF HEALTH COPY No. 00a 0- 1 -.Fee— BOARD OF HEALTH TOWN OF BARNSTABLE ApphrationArlVell Con5trurfionprrTtit .pplicat'on i: hereby made for a permit to Construct Alter or ReRair ( )an individual Well at: Location — AZ;;k Assessors Map and Parcel -'ktz&j 81A, Ow er Address Installer Driller Veo) 6- 04 Address Type of Building Dwelling Other - Type of Building No. of Persons-------- Type of Well- VC Purpose of Well----- Agreement: The undersigned agrees to install the aforidescribed 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 C rtificate of Com liance has been issued by the Board of Health. Signe J- A 0 da Application Approved By d4a ti —Adateate Application Disapproved for the following rea ——--- , -- —--^-- — / /- ---date Permit No. Issued at BOARD OF HEALTH TOWN OF BARNSTABLE Certificate Of COMPfiantP THIS IS TO CERTIFY, That the Individual Well Constructed Altered or Repaired Installer at---------- ---------------- has been installed in accordance with the provisions of the Town of Barnstable �e Bo rd of Halt Well Protection � Regulation as described in the application for Well Construction Permit No ,P--- led THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE ---------------- Inspector 3 No. Fee------------------- if\ BOARD OF HEALTH TOW N..: OF BARNSTABLE Zipplication orVell Co0tructionpermit 'A is hereby made for a permit to Construct r( ), Alter ( ); or Repair ( )an individual Well at: Zpp lication Location — Address Assessors Map and Parcel fi.� =_�n�i_lk -AIL- Owner Address At Installer — Driller PO /54 A 6 � Address Type of Building ",14111A- Dwellin Other - Type of Building---- ------- No. of Persons------------------- Type of Well YC —_-- Capacity---- — ---—-- —-- Purpose of Well-----� J --- -- Agreement: The undersigrie`d 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 C rtificate of Compliance has been issued by the Board of Health. Signed r la A lication Approved By PP PP r U are f Application Disapproved for the following reaso,,,,ps:-------------- - -------- - --- /— ----- j � date Permit No. WAV _ Issu V j date BOARD OF HEALTH TOWN OF BARNSTABLE �ertifftate ®f �Com�liante THIS IS TO CERTIFY, That the Individual Well Constructed ( ), Altered ( ), or Repaired ( ) -------- ------ ----- -- ---— - -- —— -- — — ----— ,w Installer at- -— ---------- -- - ------- ----- has been installed in accordance with the provisions of the Town of Barnstable Board of H alth P ' e Well Protection Regulation as described in the application for Well Construction Permit No.t �� ---- ed----- ------- 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 Ivell Con5truct ion Permit No. t/t/ , fee hhoz.;e�2 �Permission is hereby granted L � — ---{— ---- to Construct ( Alter ( ), or Repair ( an Individual Will a' ,/) - r—r r Street t as shown on the /application for a) ell. onstruction Permit No.-- L"t _ '�/ —---- Dated _____ 510 BoardJof Health DATE— � ` __ G✓Zr a1 No.-------------------- Fee--6----------------- BOARD OF HEALTH TOWN OF BARNSTABLE Application jbr eCr Con!9truct ion Permit /b5" Application is hereby made for a permit to Construct (—I, Alter ( ), or Repair ( )an individual Well at: le-7 3 r Location — Address Assessors Map and Parcel cl -- -- -- -- ----- Ow,ner Address Installer — Driller _ Address Type of Building Dwellingt/ Other - Type of Building ------ No. of Persons_---------------- T e of Well K�eLc_ /--- " D- -- a acit � - YP P Y------------ - Purpose of WellO..... /? �L- - —__ —v---- 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 ertificate eCpliance has been issued by the Board of Health. Signed _ `e_`�'t-/�— — (� t d dat Application Approved By =-- ------_-- `3 Zo ov date Application Disapproved for the following reasons:-------------------___ ______-- —_ ---- -- ------------------------------------------------------- date Permit No. -- Issued--- --- - - --- -------- ------ date BOARD OF HEALTH TOWN OF BARNSTABLE Certificate Of Compliance THIS TO CERTIFY, That the Individual—Well Constructed ( ), Altered ( ), or Repaired ( ) Sal 4�E /C�`! i cr r ------ —_-- -----b7Ju` Ins -- ----— -- — t er at 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. ---------___Dated THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE------ _ _ Inspector No. ------------------- Fee-- -- --------------- BOARD OF HEALTH TOWN - OF BARNSTABLE ApplicationforVell ConotructionVermit Application is hereby made for a.permit to Construct (--I, Alter ( ), or Repair ( )an individual Well at: L6cahon Address Assessors Map'and Parcel ` 1 Owner_ Address Installer — Driller �: Address Type of Building. Dwelling ✓ Other - Type of Building --- No. of Persons----------------------------__—___________ 1 `, / SRO f (/� _l rye- Type of Well------------------ ------------------ ---- �apaclty------------------ =------ ------- Purpose of 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 Co'ihpliance has been issued by the Board of Health. Signed -- � —-- dat Application Approved By e Application Disapproved for the following reasons: --------=--------------__________—__--___—_ ----- date----- Permit No. -- Issued=--— -— -------- - - date !i!iSi@i_ifi!i►ilitiKb�!i!i!i!iiKbilililibS4i�lil�L i9ilililiRi.9ili@iilifi@®ldSilitititbSTS?54ilisiKTarlivitalitGlitGOGl4lflylitPliti!!lGlilalif(ldlibiliMiTili+i!blbbs�bmoG" BOARD OF HEALTH TOWN OF BARNSTABLE Certificate Of Compliance THIS IS-TO CERTIFY, That the//I�ndividual Well Constructed ( ), Altered ( ), or Repaired ( ) by---' � - - - ------- �} Instiller --— -------- at has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection t Regulation as described in the application for Well Construction Permit No. ----------=---__Dated THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE------- Inspector _--- - -- -- iboEd@i� �f40..4['a4iii?ti+lS$i@iiii3iCifn}'14$i2ibigi4.aii�i+:S:-f@Sbi2"fi4A9iti�Rcf>ti!i}0@Y2a4iiibilB!`ubdPilibibiM4iQdMaO::b+KdiOili@i!Mibp'p iSibiliti@ib3}�(li..ibililifibifGA�lille9�i BOARD OF HEALTH TOWN OF BARNSTABLE Well Cootruction3permit � Fee- Permission is hereby granted �� "" 2� � �� to Construct ( -I-,"Alter ( ), or Re jair ( ) an Individual We t: / Street as shown on the application for a Well Construction Permit q, No.- Dated- —— -— --- ---------------------- c -- ----------------- ............. DATE � Board of ealth -- ... , i .11, ST /'h'FIV ANC L•4ROG COBS , % `(\ ( • , ,ems ' ••$� .•?, � N , . 1 1 \ ,. %, , , \ , ` \ + ., _^_ �►� /per I, .. :� ..,. �, to \ . I a p�AINS � y I 1 1 I \ - -It 1 1 , 1 kA R If it ',. •�•� n l/ .D. J. 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