HomeMy WebLinkAbout0081 WHITE BIRCH WAY - Health 81 White Birch Way
W.'Barnstable P
__ A = 128 033
` Commonwealth of Massachusetts /a g_01�3
Title 5 Official Inspection Form 4
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
r 81 White Birch Way
Property Address,
Carl & Llnda Purinton
Owner Owner's Name
information is
required for every West Barnstable MA 02668 05/13/19 ;
page. City/town State Zip Code Date of Inspection -�
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When A. Inspector Information (301 S
filling out forms
on the computer,
use only the tab Mathieu Rebello
key to move your Name of Inspector
cursor-do not Rebello Septic Inspections
use the return Company Name
key.
NorseRd
Co dr
Company Address
South Dennis MA 02660
Cityrrown State Zip Code
774-722-0271 SI-14140
Telephone Number License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 16.000); 1 have personally inspected the sewage disposal system at the property address
listed above; the information reported below is true, accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined
that the system:
1. ® Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
5/13/19
Inspector's Signature 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 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 form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note: 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.
t5insp.doc•rev.7/28/2018 Tide 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 1 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
81 White Birch Way
Property Address
Carl &Unda Purinton
Owner Owner's Name
information is required for every West Barnstable MA 02668 05/13/19
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) System Passes:
® 1 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:
2) 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):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
^ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
81 White Birch Way
Property Address
Carl &Linda Purinton
Owner Owner's Name
information is required for every West Barnstable MA 02668 05/13/19
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes(cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ 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):
i
❑ 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):
3) 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 systemi is failing to protect public health, safety or the environment.
a. 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:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
81 White Birch Way
Property Address
Carl &Unda Purinton
Owner Owner's Name
information is required for every West Barnstable MA 02668 05/13/19
page. Citylrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ 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
b. 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.
❑ 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.
c. Other:
4) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
❑ ®11 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
t5insp.doc•rev.7/26/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
81 White Birch Way
Property Address
Carl& Linda Purinton
Owner Owner's Name
information is required for every West Barnstable MA 02668 05/13/19
page. Citylrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ ® 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 flow
❑ 0 Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ 0 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.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply
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 2000 gpd-
10,000 gpd.
❑ ® 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.
5) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 16,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section CA.
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
t5insp.doc•rev.7I28I2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
Commonwealth of Massachusetts
�e Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
81 White Birch Way
Property Address
Carl & Unda Purinton
Owner Owner's Name
information is required for every West Barnstable MA 02668 05/13/19
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered"yes"to any question in Section C.5 the system is considered a significant
threat, or answered"yes"to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate"yes"or"no"for each of the following for all inspections:
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)]
t5insp.doc•rev.7126M18 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
81 White Birch Way
Property Address
Carl& Linda Purinton
Owner Owner's Name
information is required for every West Barnstable MA 02668 05/13/19
page. City/Town State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms(design): 4 Number of bedrooms(actual): 4
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 440
Description:
Number of current residents: 2-seasonal
Does residence have a garbage grinder? ❑ Yes ® No
Does residence have a water treatment unit? ❑ Yes ® No
If yes, discharges to:
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 ears usage d N/A
9 ( Y 9 (gp ))�
Detail:
well water
Sump pump? ❑ Yes ® No
Last date of occupancy: current
Date
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18
4
Commonwealth of Massachusetts
UeTitle 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
White Birch Way
Property Address
Carl &Linda Purinton
Owner Owner's Name
information is required for every West Barnstable MA 02668 05/13/19
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
2. Commercial/Industrial Flow Conditions:
Type of Establishment: N/A
Design flow(based on 310 CMR 15.203): N/A
Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.): N/A
Grease trap present? ❑ Yes ® No
Water treatment unit present? ❑ Yes ® No
If yes, discharges to: N/A
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available: N/A
Last date of occupancy/use: N/A
Date
Other(describe below):
NIA
3. Pumping Records:
Source of information: septic tank will be pumped after inspection
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped:
gallons
How was quantity pumped determined?
Reason for pumping:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
81 White Birch Way
Property Address
Carl &Linda Purinton
Owner Owner's Name
information is required for every West Barnstable MA 02668 05/13/19
Ci !Town State Zip Code Date of Inspection
page. tY P P
D. System Information (cont.)
4. 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):
Approximate age of all components, date installed (if known)and source of information:
1998 per board of health
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade: 18"feet
Material of construction:
❑cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line: N/A
feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
joints tight,proper venting, no evidence of leakage.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
81 White Birch Way
Property Address
Carl & Linda Purinton
Owner Owner's Name
information is required for every West Barnstable MA 02668 05/13/19
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
Depth below grade: 9"feet
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
1000 Gal. precast H-10
Sludge depth:
10"
Distance from top of sludge to bottom of outlet tee or baffle
24"
Scum thickness
2"
Distance from top of scum to top of outlet tee or baffle
12"
Distance from bottom of scum to bottom of outlet tee or baffle
14"
How were dimensions determined?
sludge judge
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
highly recommened pumping, tee's in place and working properly, liquid level equal with outlet invert,
no evidence of leakage from tank
t5insp.doc•rev.7/28/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18
CN Commonwealth of Massachusetts
Title 5 Official Inspection Form
M Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
81 White Birch Way
Property Address
Carl &Linda Purinton
Owner Owner's Name
information is required for every West Barnstable MA 02668 05/13/19
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap(locate on site plan):
Depth below grade: N/A
feet
Material of construction:
❑concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
N/A
Dimensions: N/A
Scum thickness N/A
Distance from top of scum to top of outlet tee or baffle N/A
Distance from bottom of scum to bottom of outlet tee or baffle N/A
Date of last pumping: N/A
Date
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
N/A
8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade: N/A
Material of construction:
❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain):
N/A
Dimensions: N/A
Capacity: N/A
p �' gallons
Design Flow: N/A
gallons per day
t5insp.doc•rev.7/26/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
81 White Birch Way
Property Address
Carl&Linda Purinton
Owner Owner's Name
information is required for every West Barnstable MA 02668 05/13/19
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank(cont.)
Alarm present: ❑ Yes ❑ No
Alarm level: NIA Alarm in working order: ❑ Yes ❑ No
Date of last pumping: N/A
Date
Comments(condition of alarm and float switches, etc.):
N/A
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
9. Distribution Box(if present must be opened)(locate on site plan):
Depth of liquid level above outlet invert N/A
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.):
t5insp.doc•rev.7/26/2018 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
81 White Birch Way
Property Address
Carl & Unda Punnton
Owner Owner's Name
information is required for every West Barnstable MA 02668 05/13/19
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ® No*
Alarms in working order: ❑ Yes ® No*
Comments(rote condition of pump chamber, condition of pumps and appurtenances, etc.):
N/A
*If pumps or alarms are not in working order, system is a conditional pass.
11. Soil Absorption System(SAS)(locate on site plan, excavation not required):
If SAS not located, explain why:
N/A
Type:
® leaching pits number:
1-6x6 w/stone
® leaching chambers number: 2-500 gal
w/stone
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
81 White Birch Way
Property Address
Carl&Linda Purinton
Owner Owner's Name
information is West Barnstable MA 02668 05/13/19
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System (SAS) (cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
6x6 leach pit found with clean an dry soil and stone with 1'of ponding found at time of inspection with
no high stain marks. Leach chambers found dry with no signs of hydraulic failure.
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration N/A
Depth—top of liquid to inlet invert N/A
Depth of solids layer N/A
Depth of scum layer
N/A j
Dimensions of cesspool N/A
Materials of construction N/A
Indication of groundwater inflow ❑ Yes ❑ No
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
N/A
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Fond:Subsurface Sewage Disposal System•Page 14 of 18
c Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
u 81 White Birch Way
Property Address
Carl& Linda Purinton
Owner Owner's Name
information is required for every West Barnstable MA 02668 05/13/19
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
13. Privy(locate on site plan):
Materials of construction: N/A
Dimensions N/A
Depth of solids N/A
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
N/A
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
81 White Birch Way
Property Address
Carl&Linda Purinton
Owner Owner's Name
required on is West Barnstable MA 02668 05/13/19
required for every
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
14. 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:
I
® hand-sketch in the area below
❑ drawing attached separately
al _ 36 aa _ 5o
A �
A3- 57 g3 _ 74
Wei I
i
i
O
3
O.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
j 81 White Birch Way
Property Address
Carl & Unda Purinton
Owner owner's Name
information is West Barnstable MA 02668 05/13/19
required for every
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water: 511+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:
USGS groundwater maps and u.s dept of interior geological survey
You must describe how you established the high ground water elevation:
Approx. from USGS groundwater maps an U.S Dept of interior geological survey indicate 51'to
groundwater
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18
° Commonwealth of Massachusetts
F Title 5 Official Inspection Form
�- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
81 White Birch Way
Property Address
Cart &Linda Purinton
Owner Owner's Name
information is West Barnstable MA 02668 05/13/19
required for every
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. Inspector Information: Complete all fields in this section.
® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked
® C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4(Failure Criteria)and 6 (Checklist)completed
® D. System Information:
For 8: Tight/Holding Tank—Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18
s.t
._ COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL'AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
t
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A U
CERTIFICATION PARCEL :_ 3
LOT --
Property Address: ) ,UfA lal�;'?L?Cec�,
Owner's Name: `'���
Owner's Addre LRE
�Ce0'
Date of Inspection: 1 (UJ3Name of Inspector: (please print �- �1. C' i'o P;" " 6LCompany Name - H DV-PT• .
Mailing Address: V.
Telephone Number: , .
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and ccmplete 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. l.am a DEP
approved system inspector pursuant to ection 15.340 of Title 5(310 CMR 15.000). The system:
Passes
Conditionally Passes
eeds Further Evaluation by the Local Approving Authority
ails
Inspector's Signature: Date: . 3 )01
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.
Notes and Comments
****This report only describes conditions at.the time of inspection^and under the conditions of use at that
different
w e system will perform in the future under the same or
time.This inspection does rot address how the y
conditions of use.
Title 5 Inspection Form 6/15/20.00 page I
T
Page 2 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
.PART.A
CERTIFICATION (continued)
Property Address:
Owner:
Date of"I spection:
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 1]0 CMR 15.304 exist. Any.failure criteria.not evaluated are indicated below.
Comments:
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.
Answer yes,no or not determined (Y,N,ND)in the for the following statementsAf"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 wi11'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.
ND explain:.
Observation of sewage backup or break out or high static water.level in the distribution box due:to broken or
obstructed pipes)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
obstruction is removed
distribution box is leveled or replaced
ND explain:
.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
obstruction is removed
ND explain:
2
Page 3 of I I
OFFICIAL INSPECTION FORM -.NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE.SEWAGE.DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:
Owner: V
Date oft pection: O
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
i
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.
_ 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 coliform
bacteria and volatile organic compounds indicates that the well is free.from pollution from that facility 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:
3
Page 4'of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE>DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: ' J
Y
WA
Owner:
Date of Ins ction: c;>('(
D. System 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 onsystein 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
9LJ
_ Liquid depth in cesspool is less than 6"below invert or available volume is less than''/z day flow
_ Required'pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
J of times pumped
W 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
watersupply.
_ 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 coliform bacteria and volatile organic compounds
indicates that the well is free from.pollution from that facility 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 mustbe attached to this form.]
A (Yes/No)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 correctthe failure.
E. Large Systems:
To be considered a large system the-system must serve a.facility with a`desigh,low of 10 000 gpd to 15;000
gPd�
You must indicate dither"yes"or"no"to each ofthe following:
(The following criteria apply to large systems in addition to the criteria above)
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 watersupply
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 questibn 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
1:5.304. 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:S `11Ah 2"LC"'A2e)4
Owner:
Date of I etion:
Check if the following have'peen done. You must indicate"yes"or"no" as to each of the following:
i
jYes w o
_ 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?
-4Z'- Has the system received normal flows in the previous two week period?
�I
61 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
V _ 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
aintenance 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 CMR 15.302(3)(b)] .
5
Page 6 of I 1
OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: UJ
✓ ,qd
Owner
Date of pection: '
FLOW CONDITIONS
RESIDENTIAL ✓
Number of bedrooms(.design): � Number of bedrooms(actual):
DESIGN flow based on 31 O.CMR 15.203{for example: 11:0 gpd x#of bedrooms): V Vo
Number of current residents:
—
Doesresidence have a garbage grinder(yes or no)
Is laimdry.on a separate sewage system (yes or no .:[if yes separate insp'ec'tion`required] '
Laundry system inspected(yes or no)
Seasonal use: (yes or no�
Water meter readings, if available(last 2 years usage(gpd)): we'll
Sump pump.(yes or no)
Last date of occupancy:
COMMERCIAL/INDUSTRIAL�I�
Type.of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgft:etc.):
Grease trap present(yes or no):_
Industrial waste holding tank present(yes or no):
Non-sanitary.waste discharged to the Title 5 system(yes or-no):
Water meter readings, if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: l
Was system pumped as part of the i spection.(ydi or 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)
_Tight tank —Attach a copy of'the DEP approval`
Z'Other-(describe).
p oximate age of all components, date installed(if known)and source of information:
Were sewage odors.detected when`arriving at the site(yes or nog
6
Page 7 of 1 I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY.ASSESSMENTS
'SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM-INFORMATION(continued)
Property Address: epao v2a-�
t' �
J
aozahzl
Owner:
Date of I pection:
BUILDING SEWER(locate on site plan)J' ""v
Depth below grade:
Materials of construction:_cast iron 40 PVC_other(explain):
Distance from private water supply well or suction,line: .
Comments(on condition of joints,venting,evidence of leakage,etc.): . •., , . .
SEPTIC TANK:_(locate on site plan)
Depth below grade:
Material of construction: Concrete_metal_fiberglass_polyethylene
other(explain)
If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of
certificate)
Dimensions:
Sludge depth;, fO)'� /I
Distance from top of sludge to bottom of outlet tee.or baffle:, Z�
Scum thickness:_ .
Distance from top of scum to top of outlet tee or baffle: —�
Distance,from bottom of scum to botto f outlet tee or baffle:
How were dimensions determined:
Comments.(on pumping recommend tions, ' let and outlet tee or baffle condition,structural integrity, liquid levels
rzs�related to outlet invert,evidence of le aka e,etc.):
i ailld
li
GREASE TRAPlocate-on site plan)
Depth below grade:
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:.,
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
7
i
Page 8 of 1]
OFFICIAL INSPECTION.FORM—NOT,FOR,VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM`INFORMATION(continued)
Property Address:
ZU
Owner:
Date of I ectiont
TIGHT or HOLDING TANK: tank must be pumped at time of inspection)(]ocate on site plan)
Depth below grade:
Material of construction: concrete metal fiberglass_polyethylene other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches, etc.):
DISTRIBUTION BOX: if present must be opened)(]ocate on site plan)
Depth of liquid level above outlet invert:
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:4�J�locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or-no):
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
8
Page 9 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: ' 1
Owner:
Date of ection: (j
SOIL ABSORPTION SYSTEM (SAS): (locate on site plan,excavation not required)
If SAS not located explain why:
Type _ _ - __.........._
eaching pits,-number:
aching chambers,number-:92
leaching galleries,number:
leaching trenches, number, length:
leaching fields,number, dimensions:
overflow cesspool,number:
innovative/alternative system Type/name of technology:
Comments(note condition o-'soil,signs of hydraulic failure; level of ponding,damp soil,condition of vegetation,
etc).
,SUO
y'
CESSPOOL(cesspool must be pumped as part of inspection)(locate on site plan).
Number and configuration: le �- � �t ✓�
Depth'—top of liquid to inlet nvert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool;.
Materials of construction:
Indication of.groundwater inf..ow(yes or no):
Comments(note condition of soil,signs of hydraulic failure,.level of'ponding,-condition ofvegetation;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.):
9
Page 10 of I 1
OFFICIAL INSPECTIONYORM_NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM-INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
r. '
Property Address:
Owner,
Date of t9p Mee tion: 2,(� (ll)03
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.
04 40Y)U1
r
10
Page I I of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: A ) �
GC/
Owner:
Date.of I ction:
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 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:
11
Permit Number: Date:
Completed'by: �
HIGH GROUND-WATER LEVEL COMPUTATION.
Site Location:. ✓ A Lot No.
Owner: Address:
Contractor: Address: jWy
Notes:
STEP 1 Measure depth to water table }
to nearest 1✓10 ft. .................................... /
:......................................... .Date
month/day/Year
STEP 2 Using Water-Level Range Zone
and Index Well Map locate
site and determine:
Appropriate.index well......................................
OBWater-level range zone .............:......
STEP 3 Using montl-ly report "Current
Water Resources Conditions" -
determine current depth to
water level for index well ...........................
month/year
STEP 4 Using Table of Water-level Adjustments
for index well (STEP 2A), current depth
to water level for index well (STEP 3).,
and water-level zone (STEP 2B)
determine water-level adjustment.............................
.:.....................:........................................
STEP 5 . Estimate depth to high water
by subtracting the water-
level adjustment (STEP 4)
from measured depth to water
levelat site (STEP 1) .:.............................................................................................................. 7
Figure 13.--Reproducible computation forma
15
i ..
I '
�...r'
.._...w,......,....�...,,m.h,,,�,�,,,,,<�,...�J* ___._..........a...__,.,_._...ma�.....m...,.�m _T......._.�.,. t^��...,,,..;:��:.:..u..�,....,..�..,....W�.p. _liit`+��!/'�`i�J...,,w_w..,._
.�.._._._.___._..______�...__.._...�....o.. � .�...� . ,.._...._..... ....
� - .
�.� .�w,
J
J _
°{ CERTIFICATE OF ANALYSIS
Page: 1
'ssgCHusti�%� Barnstable County Health Laboratory
Report Prepared For: Report Dated: 8/5/2003
Purinton,Carl&Linda Order Number: G0321206
Carl Purinton
29 Noah Chapin Drive RECEIVED
Somers, CT 06071
AUG 0 7 2003
Laboratory ID#: 0321206-01 Descrintion: TOWN OF BARNSTABLE
Water-Drinking Water HEALTH DEPT.
Sample#: 21206 Samuline Location: 81 White Birch Way,West Barnstable Collected 7/10/2
Collected by: C.P. 128-033
Received 7/10/2003
Routine
ITEM RESULT UNITS MCL Method# Tested
LAB: IC Lab
Nitrates 0.4 mg/L 10 EPA 300.0 7/14/2003
LAB: Metals
Copper 0.3 mg/L 1.3 SM 3111B 7/29/2003
Iron <0.1 mg/L 0.3 SM 3111B 7/29/2003
Sodium 14 mg/L 20 SM 3111B 7/29/2003
LAB: Microbiology
Total Coliform Absent P/A Absent 309 7/10/2003
LAB: Physical Chemistry
Conductance 129 umohs/cm EPA 120.1 7/11/2003
PH 7.6 pH-units EPA 150.1 7/11/2003
Note: Water sample meets the recommended limits for drinking water of all above tested parameters.
Approved By:
b Director)
09 0 �
r
S
Superior Court House, PO.Box 427, Barnstable, MA 02630 Ph: 508-375-6605
TOWN OF BARNSTABLE =C.
LOCATION V "41&. Alf-)ee4 41al SEWAGE #
VILLAGE W I A8 efO sZa',6 /e- 11 ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) 600,",L 10W I C'Aq,*!-j /�� (size)
NO.OF BEDROOMS 3
BUILDER O OV✓NF t✓7
PERMIT DATE: - /g`9y COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility J Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) /540 Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
1 .e
O
S ov
Pee
No. Fee✓&
THE COMMONWEALTH OF MASSACHUSETTS
Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS
ZIPPYication for Zioogar *pgtem Congtruction Permit
Application for a Permit to Construct( )Repair( /Upgrade( )Abandon( ) El Complete System L'7In1vidual Components
Location Address or Lot No. Q^/ �.>�,1 Q . Owner's Name,Address and Tel.No.
Assessor's Map/Parcel 00�lP� /����C�/�
Installer's Name,Addre and Tel. o. Designer's Name,Address and Tel.No.'
�O�j
a 7/-I9fl
Type of Building:
Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder
Other Type of Building > ,-j1GeNo. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow ��D gallons per day. Calculated daily flow - ? gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank A"6_117 1e5;r11 1 1°9 Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable).
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a`Certifi-
cate of Compliance has been issV;N
ar f Heal
_
Signed Date �!��G�g Application Approved by f -- -- Date
Application Disapproved for We folli4ving reasons
Permit No. - 362 A Date Issued
i
TOWN OF BARNSTABLE
LOCATION �� W�i' e4,1 �✓a SEWAGE #
VILLAGE ;OR'S MAP & LOT�Z8'O33
INSTALLER'S NAME&PHONE NO. BO/`rOLeJf`/ 6es, : 77/9&PZ
SEPTIC:TANK CAPACITY /V Ga L
LEACHING FACILITY: (type)f'o6e for# e 1.4 (size) /.�,3+:�s_•�?
NO.OF BEDROOMS 3
BUILDER,0��
PERMIMATE: G-/S-9S� COMPLIANCE DATE:
Separat o.6.Distance Between the:
aximiirti:Adjusted Groundwater Table to the Bottom of Leaching Facility Feet .
i Private?Water Supply Well and Leaching Facility (If any wells exist r
on:si(e or within 200 feet of leaching facility) /nd Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
withi":300 feet of leaching facility) Feet
Furnistied;by
_ I
O
I M W
11,as' bf I'
o3.3'
No. t(/ Fee
THE COMMONWEALTH OF.MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
Application for ;Digp/ogar *pgtem Congtruction j3ermit
Application for a Permit to Construct( )Repair( Y)Upgrade( )Abandon( ) El Complete System Tlndividual Components
Location Address or Lot No. /./ �,ty r �/`y Owner's Name,Address and Tel.No.
Assessor's Map/Parcel
Installer's Name,Address,and Tel.No. �f �J t Designer's Name,Address and Tel.No.
7 7/�9399
Type of Building:
Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( �
Other Type of Building e.51 e&e-e No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow /4 1 gallons per day. Calculated daily flow 3 34:::7 gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) file
Date,last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued y t 's par of Hea
Signed Date
Application Approved by °S7 Date
Application Disapproved forWe folfJwing reasons
Permit
e tt No. :3 Date Issued
THE COMMONWEALTH OF MASSACHUSETTS 1 7,8--03 3
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CE TIFY, than}the p-site,,S ewage Disposal System Constructed( )Repaired (✓�-,)Upgraded( )
Abandoned( )byO! DLOe, /
at 5/ WII/ )14 �- ,k/ 4 05AP,d G has been constructed in accordance
wit4the provisions of Title 5 and the for Disposal System Construction Permit No. A dated
Installer Designer
The issuance of this permit shal qot b�j construed as a guarantee that the syste l unction as designed.
Date - 1 ' / Inspector It
r 4
/ Fee
No. - — �J7 A -------------------�!r U �- —
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
ligogar *pgtem Congtruction permit
Permission is hereby granted to C nstruct( )Rep (t/�pgrade( )Abandon( )
System located at tr/ W 7 i/rr7Wq
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided:Construction must be completed within three years of the date of this permit.
Date: Approved by
IWN7
NOTICE: This Form Is To Be Used For the Repair Of Failed
Septic Systems Only.
CERTIFICATION OF SKETCH AND APPLICATION FOR A
DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT
ENGINEERED PLANS)
hereby certify that the application for disposal works
construction permit signed by me dated �l Q! �� ;concerning the
P ..
property located at meets all of the
following criteria:
✓ here are no wetlands located within :oo fee:of:he proposed leaching facility
�T' ere are no orivate wells within i:o :eet of:he:r000sed septic system
i✓ � :h
ere s no :ncreare in now and/or ange :n-ise ar000sed
i.ere are no variances reouested or needed.
If the proposed IeachinQ ac iity will ocmec-.vithin ::o tee,of anv wetlands, the bermrn of:he
proposed leaching faciiiry wiil not'-.e .ccated :ess:han :ourteen ,,:- :ee, above :he :max:murn ad.ustec
groundwatir tab eievation.
Please complete the following:
A)Top of Ground Elevation according:o the Engineering Division G.I.S. ,napi
B)Observed Groundwater;abie Elevation(according to Health Division well map)
- DATE:SIGNED ATE.
LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER
[Attach a sketch plan of the proposed system.Also if the licensed installer posesses a certified plot plan,
this plan should be submitted].
F hum hider.oat =
ppoqo--*Z v4
/ %`V�',�,�1�` ��cJd`
I
S �
I
�/4-7 r3�
L
No.....,�1.^..lu 1 FE$......Ie....._
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
......... ..7 v v............0F........./ %!V 5�! 1 ...........
------------------_.
Appliratiou for Ui.gpusttl Wnrkii Tonstrixrtiurt Prrutit �
Application is hereby made for a Permit to Construct (X) or Repair ( ) an Individual Sewage Disposal
Systpai at:
........... &A...... ...................
21.... �IIIW4.............. .......
oLfat—ion Address or Lot No.
.. _. a.tlL �...
a ..
Owner
. Address
............................ ........ .........-•.--••--....----••-•-------•......................_...._................................
Installer
Address
Type of Building Size Lot...� 3.1.91,?...Sq. feet
..� Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) I
Other—T e of Building No. of persons............................ Showers
a YP g ••.........................• P ( ) — Cafeteria ( )
Other fixtures -----•------•--•--••-•-- _.. . .........................
�� � -•-----8`a Pe �,-c��y.•-----------------y.fln...:-----...�� ............gallorf�..
Design Flow................. .... ...... .. llons r Total da- w..._........._. ..._ .. .
W Septic Tank—Liquid capacity. allons Length�.. ...6_... Width:.. jt�.. Diameter:............... Depth .��.....
L
x Disposal Trench—No- ------------------- Width.................... Total Length.................... Total leaching area....................sq. ft.
3 Seepage Pit No.........L.......... Diameter.........f.G).... Depth below inlet......la.......... Total leaching area..... .�......sq. ft.
Z Other Distribution box ( Dosing ta
Q
aPercolation Test Results, Performed by...........1....... ..T �C P .. Date...�.-. ..Cl...............
1 Test Pit No. 1......2,minutes per inch Depth of Test Pit....._/ . Depth to ground wate ..
P P � T�- P �' - •-�j-,--
f� Test Pit No. 2................minutes per inch Depth of Test Pit..................... Depth to ground water........................
------------------------------------•--•--• .......
• .... ...
0 Description of Soil.....
V �B . --•--•................... .....-...... .._.......------•---.........---............... ......•........•••.....
W
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:I':U 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until-a Certificate of Compliance has been issued by the board of health.
Signed.................. ------�\ ...................... -------
I ._....
} --•-----.... Date
ems+�'�- ....Application Approved By.........��- . V ,[�. u.. �..... �el- .. `1 ....
V Date
Application Disapproved for the following reasons:.......................••----.............------------....----......---------............. ...................
,y•/' •- --../•----........................................................_..•--------.---•-............_.....--•----•---•.-•---....Date.....
Permit No..........9 . Cy
-- -- •-4...-•-•............. Issued......................................................
..
Date
No. FEs
..........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF "HEALTH
...........7 ...........OF..........Ahlm;l ................................
,.Applirativii for llwpoiial Nforkri Ganatrnrtinn hermit
Application,is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal
Sys, at: � 7,7 �
..................... . ........................(iU ......................
ocation'�Address or Lot No.
... . .................................................... ............................................... ...............................
Owner Address
................4
............................ ............... ......... .................................................................................................
Installer Address
Type of Building Size Lot. ...Sq. feet
—No. of Bedrooms.................Dwelling ...........................Expansion Attic Garbage Grinder
9k Other—Type of Building ............................ No. of persons_...................._...._. Showers Cafeteria
114 Other fixtures ......................................22q�r�
t ------------- ---------*--------—--------------------------------------------
Design Flow............../ Z. ......gallons per
person per day. Total daqy Vw................. ._.._.......gallons.
—Liquid capacii y allons Length .... Width..ef...��_ Diameter`............... Depth.C.I/.....
Septic Tank
Disposal Trench—No..................... Width.....................Total Length.................... Total leaching area_...................sq. f t.
Seepage Pit No.........I........... Diameter.........I.D.... Depth below inlet......140.......... Total leaching area'7-6 ....'sq. ft.
Z Other Distribution box (\"),( Dosing tank-( )
Percolation Test Results Performed by...........i .....P _.. Date.............
�4 if
`52 u ter 1.4 Test Pit No. I.._.... —,minutes Depth of Test Pit....11.1�Lj...... Depth to ground c,
(Z4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.........V... ......
P4 .............................................................................................................................................................
0 Description of Soil...*��? ----------**------*"*......*--------------------------------**------- --------*...........***...........
------------------------ ----------I-------------- ----------------------------------------------------------------------------------------------------------------------------------------
.......................................................................................................................................................................................................
tU 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 TAITLZZ 5 of the State'Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
.......D.....( el't, ......................
Signed................e. ........4x;;�
Date
Application Approved By......... .. ..... ............
U Date
Application Disapproved for the following reasons:............................................................................................................
........................................................................................................................................................................................................
Date
PermitNo.......... .................... Issued........................................................
Date
---------- ------------- -------------- ----------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
1.
....OF.............. .........1-. . .. ..........................................
Tatifirate jaf Toutpliattrit
THIS IS TO CERTIFY That the Individual Sewage Disposal System constructed^ ) or Repaired
by............... ....... .............................................................................................................................
, Installer
at.......4��127..?........V/ Q.P.� ..^
........... -jo
---�U.......P(�...............................................................................
has been installed in accordance with the provisions of TITLE 5 U The State Sanitary Code as described in the
application for Disposal Works Construction Permit No.._...._21./............$.'�......... dated_........__....................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
4;4:11 - 61
DATE............ ....................................................... Inspector-------------------------------- •••--•._............... e
----------- ---------I--------------------------------------------------------------- ----------- -----------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
4
....... .,�............OF......... .................................
N —..5�/) -
0..,/... ...........
Disposal 10orks Tung radian Vantit
Permission is hereby granted......... ........... ...................................................................................
to Construct or Repair an Individual Sewage Disposal S�stem
H.. 01................. .....at No.........,, ...7........5?'�...... .......... ........---------;...
stre�tz
as shown on the application for Disposal Works Construction Permit 0. L. Dated..........................................
---------------- "Iuv�------------------------------
DATE--------------- .................................. oard of Health
f L''L 1 JL Ii�H' LHeSr
( OFFICE
ONDQUWATERE qq r ly
� �;d' sq"'T T�� x.*ter., -m-•=<- t.,n .. 8��-
�! a`" � a}n1S
i
March 14, 199
:1_t PXup Company, Ir_c.
,. PlymoUth, Mass. 02360
r,
W 11 Water LKis,tirg t'' I.i 95 fDot &!Gp
f,
Located on thF nrOperty Cf Dan Eros .. Lot 9 - ?h'.te T;#rch zio - W. Barns tab I-.
YA
Analysis ?Yum-b!t -, I")30 Ark s I� tC4ti.
Result
p
6Gaxb 'i t"• eazlde- tip 0r.. -
�,. ,..........—....., r '� p
oroet
. .� hane0.5
pa.i+-�-i_.._..,�A.®1J d."L•°`{z'w .+-..,+A....T.c-�.T.,-.+.uri-'_*...�.�^--.�y.r...�. +- awe.=lJ9•r',*
503.
e' i cihl roet.en 03.
r.
?F �w
lD 4I GP J Y t 4:2tf.�' `t� �e+--.r.:,wr...�-w...w+.+Y.....,.� ttom.°.......«...•m.L... '" ,� �El i. .A " _{{3°.w0ewr7
0.5
+—...ter. :.,3`��1 } _�?.�,�,�--�,,..�..�,.�.�w.���►�. t
Chlo oethane
ND '502.1
INM
Chloromethane
501.1 '
-ND 0,1 ��c►�3 � (2 3 I
_..:�,. -...� .-.._-._..� �..._ i G.•1_ �str�w 1, S 503.i
_
NDr
------------
- isZ�f �:tlorc�sra��re �
502.1 t
tvremn
° r
OFFICE
: 14 E•tid3�d S' T LABORATQFtY
' 13FODGMATC-P, INA 02NZ6u 170 PLYMOUTH STREW
MUGEB''VATEP,MA 04.24
CHEMICAL 8' *e . e4Ya 1
i TEL(#�0) t��l
pay 2'
I.rTAut batcon Yytical
u 1 Hethod
1,142-Trichloroathjne '.
--"""'
1 1,1 2-Vetrachloruathatte • i,
1 - 2 �Tetsachlcraethan � %T d,l
50
Tetrachloroett�&Y -*are
f 1,7 3�-Tr.ichloropropar�e t�'II
"_""." •.
. r
: fie
Dichloradiflunromethane IND
:
Flnoratri,^hlarax��thane
rD
r 'gjii0 "t53S 'l rIl
. ........
`i—Pr t11Iboenzare
tF �.��..�...�._.._......�._�... tip#
a r ^t7tlty1ber"tzena ��� ,..+.�.�.,► Ua J #
"T a'4 i '.Jbenm 14V
,,....,®.
VID
1�,2 -4-- Trimathy ben2ene 'IN pw
X .y�fir{ a thvl ben�an r 3 FT -----" -i
... _ _ ,....F�...
the Hn + nibromida (EDB) _ 3D S
U.t 1 04
2M-D i lb roYX o-3
+chlo-f-oFxa2ane (DPCP) I504
1 Notts: 14M -- None Detected (Balow minimum det etable lml T MDQ
i -
TeNted by Lab W.A022
rip t'i'n:2 ; p f eP,��wa4£*il � L�11T 4 a
1.,2 4 chl.crobenzene-d. 92 80_120
5<a1�1fi� coll:,-cted by M riQ, Well & Fu-.op Co. - 21213r 91.
Sample dcliw:-red to laloratoxy b} Pilgrim We!I & r'larip Co. - 2,"3191 at 8:45
�Direttor
OFFICE LABORATORY
1498 HIGH STREET 176 PLYMOUTH STREET
BRIDGEWATER, MA 02324 BRIDGEWATER, MA 02324
OLIVEIRA ENVIRONMENTAL LABORATORIES, INC.
FOOD- DAIRY PRODUCTS-WATER-WASTEWATER
CHEMICAL Ft BACTERIOLOGICAL ANALYSES
(508)697-2650
February 5, 1991
Pilgrim Well & Pump Co. , Inc.
26 Camelot Drive
Plymouth, Mass. 02360
Source: Well Water - Bored Well With Well Point - 95 feet deep
Located on the property of Mr. Daniel Enos - Lot 9 - White Birch Road -
West Barnstable, Mass.
Coliform Count
/100 ml @ 35 C 0
Membrane Filter
S.P.C./ml
@35C 52
Color (APC units) 0.00
Sediment slight
Turbidity (NTU) 1.90
Odor none
Taste satisfactory
pH 7.00
Specific Conductance 70.0
micromhos/cm
mg /liter
Total Alkalinity (CaCO,,) 13.0
Free CO2 2.52
Total Hardness (CACO,) 18.0-1
Calcium (Ca) 4.80
Magnesium (Mg) 1.46
Sodium (Na) 7.50
Potassium (K) 0.70
Total Iron (Fe) 0.02
Manganese (Mn) L 0.01
Silica (SiO2) 15.0
Sulfate (SO4) L 1.00
Chloride (CI) 12.5
Nitrogen - Ammonia L 0.01
Nitrogen - Nitrite 0.003
Nitrogen - Nitrate L 0.10
Copper (Cu)
L = less than
Bacteriologically, this well water is of a satisfactory sanitary standard and is
suitable for drinking and domestic purposes.
Chemically, this well water meets the standards for all of the chemicals tested.
On site collection made by Mr. Bruce Bishop of the Pilgrim Well & Pump. Co., - 2/1/91.
Sample delivered to laboratory by Mr. Mark Bishop - 2/1/91 at 10:00. A.M.
Director
a
_ fT�
The Standard Plate Count indicated the general bacterial population of the well at the time of collection.
Coliform Group Bacteria:
Significance
The coliform group bacteria includes organisms found in the intestinal tracts of warm blooded animals, birds,decaying organic matter(hay,
leaves, wood, etc.), the top 2 to 3 feet of the soil, lakes, ponds, brooks, rivers, drainage and types of vegetation.
Because the organisms can cause some illness; because the presence of coliform organisms in the water suggests that other more harmful
organisms may be present, water containing one or more coliform group bacteria per 100 ml of sample should not be used for drinking or
cooking purposes unless boiled 5 minutes or disinfected by other means.
This bacteria is of animal origin (intestinal tract)and may be considered as closely associated with disease causing organisms.On this factor,
none should be present.
Color — APC Units- Ground water ought to be practically free from color. For attractive water- color should not exceed 15 units.
Turbidity — NT Units- Recommended limit not to exceed 5 units.
Odor£t Taste — For water to be of high quality, the water should be odor free and taste good.
pH — The pH value defines the concentration of free hydrogen ions in solution. Expressed on a scale extending from 0 or very acid to 14 or
very alkaline with 7.0 being neutral.
Specific Conductance — Conductivity is a good criterion for measuring the degree of mineralization and assessing the affect of diverse ions
on chemical equilibria.
Total Alkalinity — The alkalinity of this water represents its content of carbonates and bicarbonates.
Free Carbon Dioxide — Well water having a low pH and a Free CO, level in excess of 50. mg/I will be corrosive to iron, bronze, brass and
copper tubing and fittings.
Total Hardness — Standard not to exceed 50. mg/l. Waters having a hardness level of 50 to 100 are in the medium hardness range, over
100 very hard.
Calcium -- Calcium contributes to the total hardness of water.Appreciable amounts of calcium salts break down on heating and form scale
in boilers, pipes and cooking utensils.
Magnesium — Magnesium is a common constituent of natural water. Magnesium and calcium ions are principal contributors to water hard-
ness. Concentrations in excess of 125 mg/1 can exert a cathartic and diuretic action.
Sodium — Recommended limit not to exceed 20 mg/I.
Potassium — Potassium concentrations in drinking water seldom exceed 20. mg/I.
Total Iron — Standard not to exceed 0.3 mg/l.
Manganese — Standard not to exceed 0.05 mg/I.The principal reason for limiting the concentration of manganese is to reduce esthetic and
economic problems.
Silica — Silica content of natural water is most commonly in the 1 to 30 mg/I. Silica in water is undesirable because it forms difficult to
remove silica scales.
Sulfates — Standard not to exceed 250 mg/l.
Chloride — Standard not to exceed 250 mg/I.
Nitrogen — Ammonia is present in variable concentrations in many surface and ground waters. Its occurrence in ground water is generally a
result of natural reduction processes.
Nitrogen - Nitrite — Nitrite in water poses a health hazard, but fortunately seldom occurs in high concentrations. Waters with a nitrogen -
nitrite concentration over 1 mg/I should not be used for infant feeding.
Nitrogen - Nitrate — Standard not to exceed 10. mg/l. Nitrate, in high concentrations can and do cause methemoglobinemia or so-called
nitrate poisoning in infants. Water with 10 or more mg/I of nitrate is unsatisfactory and is not considered safe for drinking or cook-
ing. It is especially dangerous to children and should never be used in infant formulas.
Copper — Standard not to exceed 1.0 mg/l.
F83384-2
T -
No. Fee
_ _ _y_ c _____:
-
BOARD OF HEALTH
TOWN OF BARNSTABLE
Yicat ion i orlVeir Con0ruction ermit
Ap ication is hereby made for a permit to Construct (✓rAlter ( ), or Repair ( )an individual Well at:
A_';O'V�g -- �% __ 1 r -------- ---------------------------- -----------P-----------------------------------------
� Location — Add Assessors Ma and Parcel
Nte o S ppD
Owner Address
-------
----------------------------------------------------—---------------—----------------
-----
Installer — Driller Address
Type of Building
Dwelling------------------ -------------------------------------------
Other - Type of Building -------------------- No. of Persons------—-------------------------------------_-____
Type of Well-- ---- -C4'�' E _----------_--------- Capacity
Purpose of Well-14-OA1--U,,A-2
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 C tificate of Co liance has been issued by the Board of Health.
Signed -- - ------------------ a__ .: '71
date
Application Approved By--------
-__� ' ' =_ r -'-�-- ----- - ' date ` --
Application Disapproved for the following reasons:-----------------------------------------------_--------------_____---____---_---____
date
Permit No.—_-��✓ `-----------------------------
----------- Issued--------------------------------------- — - -- - ------------
--
date
BOARD OF HEALTH
TOWN OF BARNSTABLE
Certificate ®f Compliance
THIS IS TO CERTIFY, That the Individual Well Constructed (cO',"�Altered ( ), or Repaired ( ) -
b - ------------- - -----------------------
-- -
Installer
at-- _ —'l�l- -- /ram: ._ le
it - - - --- --� ___��.___1_���-r-bra.�---------------------------------------------------------
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- --- ------------- ----—- - - - -
L
No.-------------------- Fee---------------------
BOARD OF HEALTH
TOWN OF BARNSTABLE
A.ppfitationforlVerr Con,9truttionPermit
Application is hereby made for a permit to Construct (V),Alter, ( ), or Repair ( )an individual Well at:
v -- — — — P — —— — — — —
Location — Add re s� Assessors Ma and Parcel
=- -----------------------------------------------------------------------------------------
Owner Address
------------------
Installer — Driller Address
Type of Building
Dwelling-------------------------------------------------------------------
Other - Type of Building ----- No. of Persons------------------------------------------------------
Type of Well-- 4/ --5 R E E'�/� —---- 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 T-L f-'V,Fr e- , , - -- -- _8
date
-� - -ice---..- - -f 2-1 ------
LIZ- ------=--- ate
Application Approved By-__________�__-�����,_2,
Application Disapproved for the following reasons:-------------------------------------------------------------------------------
------ -------------------------------------------------------------------------------------------------------------------------------------
/ date
PermitNo. --------------------r ------------------------ Issued-------------------------------------------------------------- - ----
date
BOARD OF HEALTH
_ TOWN OF BARNSTABLE
Certificate Of Compliance
1-11
THIS IS TO CERTIFY, That the Individual Well Constructed (U') Altered ( ), or Repaired ( )
---------------------------------------------------------------------------------------------------------------------------------
Installer
1 4 ��h{�' NS ire - _ "-/ - L_le - ----- - -
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. ��t-1 y----Dated Zq
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
Veil Congtruct ion Permit
�'/-Y 2J
No. ---------------------- Fee-------------------
Permissionis hereby granted--------------------------------------------------------------------------------------------------------------------------------------------
to Construct (V�, Alter ( ), or Repair ( ) an Individual Well at:
No. / : ✓-- �� �t� �� -AOG�ei1/1 ft!�ft�---------------------------------------------------------------------
Street
as shown on the application for a Well Construction Permit
No.------!44d4_- - - - - Dated - r�� g�- ---
Board of Health
DATE �I - - - - - -
i 71 VIC
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t Y
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