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HomeMy WebLinkAbout0040 WIDGEON LANE - Health 40 WIDGEON WAY ,� A = 132 048 r 0 TOWN OF BARNSTABLE LOCATION 40 A U196&)V i u,4-f SEWAGE # RC00 VILLAGE 11 ,'4y ASSESSOR'S MAP & LOT1)'� — INSTALLER'S NAME&PHONE NO. j SEPTIC TANK CAPACITY LEACHING FACILITY: (type)3 (size) NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: d COMPLIANCE DATE: i Separation Distance Between the: i Maximum Adjusted Groundwater Table and.Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200'feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by µ TON'N OF BARNSTABLE' L OCAPO T` A SEWAGE # RC00 R V— VILS.AG ASSESSOR'S MAP & LOT/32 —0 -� INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY OLpC40 LEACHING,FACILITY: (type)3 (size) 1 NO.OF BEDROOMS BUILDER-OR OWNERC- PERMITDATE: /q-0 COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200'feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by I 7f f Azo �. 1 No�� .,'Z(f�- Fee ? V THE COMMONWEALTH1 OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Zipprication for Digogar *pgtem Coniaruction Permit Application for a Permit to Construct( )Repair(L/)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. 7�/�t As� is Map/Pa��elA�- 7 7/7 Installer's Name,Address,and Tel.No. N 4(/07Z Designer's Name,Address and Tel.No. .10 7�-mi° �R. iL Type of Building: Dwelling No.of Bedrooms 44 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building S No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow la gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank W® Type of S.A.S. Description of Soil Vsw1/. 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 Ti e 5 oft vironmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued iTi �_ X He Signed Date Application Approved by Date Application Disapproved for the following reasons Permit No. �i�' —Z�t� Date Issued — 9 — Zeo TA No ?y� t j wF� Fee THE COMMONWEA6T+- Gf MASSACHUSETTS Entered in computer: F. Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS Z(pprication for Oioo.5al *pgtem (Cougtructiou Permit Application for a Permit to Construct( )Repair(-J)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. As sry or's Map/P�el ,Yf t 3AQ _ / .y Installer's Name,Address,and Tel.No. /�d�4�C�c-rrL Designer's Name,Address and Tel.No. .10 TRf..EIW 6✓r2 CJ1'a G Type of Building: Dwelling No.of Bedrooms�_ Lot Size sq.ft. Garbage Grinder( ) Other Type of Building E S No. of Persons Showers( ) Cafeteria( ) Other Fixtures ��//'',, Design Flow * 7V40 gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. LC-i4 G5{11&iPs Description of Soil S 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 Ti e 5 of t vironmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued ' is B ar of He Signed Date ` z� Application Approved by 4ff92e= C-r Date 4/ ,/ Application Disapproved for the following reason/:( Permit No. Date Issued -- 9 - z r o --------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (Certificate of (Compliance THIS IS TO CER FY,that t e On-site Sewage Disposal System Constructed( )Repaired(�Upgraded( ) Abandoned( )by 50 at k janWft CdMW Gv i c-/h X-o in LA"t kJ (TA- PA as been constructed in accordance with the provisions of Title 5 and the for Disposal System;Construction Permit No.ZW- ZVJ dated Installer a/�//gN/-I`/D T7t Designer / O The issuanc thisPe s s nnit shall not be construed as a guarantee thatiLthe te will function a designed. Date 0 Inspector UA to ——————————————————————————————————————— No.rZnljl — [,yS Fee _ ,'� THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS lwi,�pogai *pgtem (Construction Permit Permission is hereby granted to Construct( )Repair(v)Upgrade( )Abandon( ) System located at �46 C4_11,9,oelll C.V qA 4 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 ermit. Date: y- /9- 7.470 Approved by /�/ 1/6/99 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 DESIGNED PLANS) I, RW Z 9 Y0 , hereby certify that the application for disposal works construction permit signed by me dated -00 , concerning the property located at ;}© � meets all of the following criteria: �e The failed system is connected to a residential dwelling only. There are no commercial or business uses associated with the dwelling. `• The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. �v• There are no wetlands within 100 feet of the proposed septic system )• There are no private wells within 150 feet of the proposed septic system \+ There is no increase in flow and/or change in use proposed 4 There are no variances requested or needed. ti The bottom of the proposed leaching facility will not be located less than five feet above the maximum adjusted groundwater table elevation. [Adjust the groundwater table'using the Frimptor method when applicable] \9 If the S.A.S. will be located with 250 feet of any vegetated wetlands,the bottom of the proposed leaching facility will not be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation, Please complete the following: A) Top of Ground Surfac ation(using GIS information) I2 B) G.W.Elevation +the MAX.High G.W. Adjustment. _ ,LD DIFFERENCE BETWEEN A and B 7 SIGNED : DATE: [Sketch proposed plan of stem on back]. q:health folder.cert CJ,�vG fog 3 6gwN Mhwi s CERTIFICATE OF ANALYSIS Page: 1 Barnstable County Health Laboratory ys�c�ru `. Report Prepared For: Report Dated: 4/3/2007 LeeAnn&Tom Bergal Order No.: G0739888 40 Widgeon Way West Barnstable, MA 02668 Laboratory ID#: 0739888-01 Description: Water-Drinking Water Sample#: Sampling Location 40 Widgeon Way,W.Barnstable,MA Collected: 3/28/2007 Collected by: L.Bergal Kitchen Sink with Filter Received: 3/28/2007 Routine +Ammonia ITEM RESULT UNITS RL MCL Method# Tested Ammonia ND mg/L 0.20 EPA 350.3 3/28/2007 Nitrate as Nitrogen 0.53 mg/L 0.10 10 EPA 300.0 3/28/2007 Iron ND mg/L 0.10 0.3 SM 3111B 3/30/2007 Sodium T 45 mg/L 1.0 20 SM 3111B 3/30/2007 Total Coliform Absent P/A 0 0 SM9223 3/28/2007 Conductance 230 umohs/cm 2.0 EPA 120.1 3/28/2007 pH 9.7 pH-units 0 EPA 150.1 3/28/2007 Sodium level is above the maximum contaminant level. Those on a low sodium diet may wish to consult aphysician. ND=None Detected RL = Reporting Limit MCL=Maximum Contaminant Level Superior Court House, PO.Box 427, Barnstable, MA 02630 Ph: 508-375-6605 r- , CERTIFICATE OF ANALYSIS Page: 2 Barnstable County Health Laboratory Report Prepared For: Report Dated: 4/3/2007 LeeArm&Tom Bergal Order No.: G0739888 40 Widgeon Way West Barnstable, MA 02668 Laboratory ><D#: 0739888-02 Description: Water-Drinking Water Sample#: Sampling Location 40 Widgeon Way,W.Barnstable,MA Collected: 3/28/2007 Collected by: L.Bergal Kitchen Sink with Filter Received: 3/28/2007 Test Parameters ITEM RESULT UNITS RL MCL Method# Tested Copper ND mg/L 0.10 1.3 SM 3111B 3/30/2007 Lead ND mg/L 0.0001 0.015 EPA 200.9 3/29/2007 Water sample meets the recommended limits for drinking water of all the above tested parameters. ND=None Detected RL = Reporting Limit MCL=Maximum Contaminant Level Superior Court House, PO.Box 427, Barnstable, MA 02630 Ph: 508-375-6605 CERTIFICATE OF ANALYSIS Page: 3 Barnstable County Health Laboratory ysSRc ` Report Prepared For: Report Dated: 4/3/2007 LeeAnn&Tom Bergal Order No.: G0739888 40 Widgeon Way West Barnstable, MA 02668 Laboratory ID#:1 0739888-03 Description: Water-Drinking Water Sample#: Sampling Location 40 Widgeon Way,W.Barnstable,MA Collected: 3/28/2007 Collected by: L.Bergal Outside Well Received: 3/28/2007 Routine +Ammonia ITEM RESULT UNITS RL MCL Method# Tested Ammonia ND mg/L 0.20 EPA 350.3 3/28/2007 Nitrate as Nitrogen 0.45 mg/L 0.10 10 EPA 300.0 3/28/2007 Copper ND mg/L 0.10 1.3 SM 3111B 3/30/2007 Iron ND mg/L 0.10 0.3 SM 311IB 3/30/2007 Sodium 9.4 mg/L 1.0 20 SM3111B 3/30/2007 Total Coliform Absent P/A 0 0 SM9223 3/28/2007 Conductance 130 umohs/cm 2.0 EPA 120.1 3/28/2007 pH 6.8 pH-units 0 EPA 150.1 3/28/2007 Water sample meets the recommended limits for drinking water of all the above tested parameters. Approved By: (Lab�JD�.to�,) ND=None Detected RL = Reporting Limit MCL=Maximum Contaminant Level Superior Court House, PO.Box 427, Barnstable, MA 02630 Ph: 508-375-6605 CERTIFICATE OF ANALYSIS Page: 1 4i J Barnstable County Health Laboratory �ssAcmy Report Prepared For: Report Dated: 4/3/2007 LeeAnn&Tom Bergal Order No.: G0739888 40 Widgeon Way West Barnstable, MA 02668 Laboratory ID#: 0739888-03 Description: Water-Drinking Water Sample#: Sampling Location 40 Widgeon Way,W.Barnstable,MA Collected: 3/28/2007 Collected by: L.Berg.al Outside Well Received: 3/28/2007 EPA 524.2- Volatile Organics by GC/MS ITEM RESULT UNITS RL MCL Method# Analyst Tested Note Dichlorodifluoromethane ND ug/L 0.5 EPA 524.2 yn 3/29/2007 Chloromethane ND ug/L 0.5 EPA 524.2 yn 3/29/2007 Vinyl chloride _ ND _ ug/L 0.5 2.0 EPA 524.2 yn_ 3/29/2007 Bromomethane ND ug/L 0.5 EPA 524.2 yn 3/29/2007 1,1,1,2-Tetrachloroethane ND ug/L 0.5 EPA 524.2 yn 3/29/2007 1,1,1-Trichloroethane ND ug/L 0.5 200 EPA 524.2 yn 3/29/2007 1,1,2,2-Tetrachloroethane ND ug/L 0.5 EPA 524.2 yn 3/29/2007 1,1,2-Trichloroethane ND ug/L 0.5 5.0 EPA 524.2 yn 3/29/2007 1,1-Dichloroethane ND ug/L 0.5 EPA 524.2 yn 3/29/2007 1,1-Dichloroethane ND ug/L 0.5 7.0 EPA 524.2 yn 3/29/2007 1,1-Dichloropropene ND ug/L 0.5 EPA 524.2 yn 3/29/2007 1,2,3-Trichlorobenzene ND ug/L 0.5 EPA 524.2 yn 3/29/2007 1,2,3-Trichloropropane ND ug/L 0.5 EPA 524.2 yn 3/29/2007 1,2,4-Trichlorobenzene ND ug/L 0.5 70 EPA 524.2 yn 3/29/2007 1,2,4-Trimethylbenzene ND ug/L 0.5 EPA 524.2 yn 3/29/2007 1,2-Dibromo-3-chloropropane ND ug/L 0.5 EPA 524.2 yn 3/29/2007 1,2-Dibromoethane(EDB) ND ug/L 0.5 EPA 524.2 yn 3/29/2007 1,2-Dichlorobenzene ND ug/L 0.5 600 EPA 524.2 yn 3/29/2007 1,2-Dichloroethane ND ug/L 0.5 5.0 EPA 524.2 yn 3/29/2007 1,2-Dichloropropane ND ug/L 0.5 EPA 524.2 yn 3/29/2007 1,3,5-Trimethylbenzene ND ug/L 0.5 EPA 524.2 yn 3/29/2007 1,3-Dichlorobenzene ND ug/L. 0.5 EPA 524.2 yn 3/29/2007 1,3-Dichloropropane ND ug/L 0.5 EPA 524.2 yn 3/29/2007 1,4-Dichlorobenzene ND ug/L 0.5 5.0 EPA 524.2 yn 3/29/2007 2,2-Dichloropropane ND ug/L 0.5 EPA 524.2 yn 3/29/2007 2-Chlorotoluene ND ug/L 0.5 EPA 524.2 yn 3/29/2007 4-Chlorotoluene ND ug/L. 0.5 EPA 524.2 yn 3/29/2007 Benzene ND ug/L 0.5 5.0 EPA 524.2 yn 3/29/2007 Bromobenzene ND ug/L 0.5 EPA 524.2 yn 3/29/2007 Bromochloromethane ND ug/L 0.5 EPA 524.2 yn 3/29/2007 Bromodichloromethane ND ug/L 0.5 EPA 524.2 yn 3/29/2007 Bromoform ND ug/L 0.5 EPA 524.2 yn 3/29/2007 ND=None Detected RL = Reporting Limit MCL=Maximum Contaminant Level Superior Court House, PO.Box 427, Barnstable, MA 02630 Ph: 508-375-6605 �" " : CERTIFICATE OF ANALYSIS Page: 2 Barnstable County Health Laboratory 9ssRCFruuS``fi Report Prepared For: Report Dated: 4/3/2007 LeeAnn&Tom Bergal Order No.: G0739888 40 Widgeon Way West Barnstable, MA 02668 Laboratory ID#:1 0739888-03 Description: Water-Drinking Water Sample#: Sampling Location 40 Widgeon Way,W.Barnstable,MA Collected: 3/28/2007 Collected by: L.Bergal Outside Well Received: 3/28/2007 EPA 524.2- Volatile Organics by GUMS ITEM RESULT UNITS RL MCL Method# Analyst Tested Note Carbon tetrachloride ND ug/L 0.5 5.0 EPA 524.2 yn 3/29/2007 Chlorobenzene ND ug/L 0.5 100 EPA 524.2 yn 3/29/2007 Chloroethane _ ND _ ug/L 0.5 EPA 524.2 yn 3/29/2007 Chloroform 0.59 ug/L 0.5 80 EPA 524.2 yn 3/29/2007 cis-1,2-Dichloroethene ND ug/L 0.5 70 EPA 524.2 yn 3/29/2007 cis-1,3-Dichloropropene ND ug/L 0.5 EPA 524.2 yn 3/29/2007 Dibromochloromethane ND ug/L 0.5 EPA 524.2 yn 3/29/2007 Dibromomethane ND ug/L 0.5 EPA 524.2 yn 3/29/2007 Ethylbenzene ND ug/L 0.5 700 EPA 524.2 yn 3/29/2007 Hexachlorobutadiene ND ug/L 0.5 EPA 524.2 yn 3/29/2007 Isopropylbenzene ND ug/L 0.5 EPA 524.2 yn 3/29/2007 Methylene chloride ND ug/L 0.5 5.0 EPA 524.2 yn 3/29/2007 Methyl-tert-butyl ether ND ug/L 0.5 EPA 524.2 yn 3/29/2007 Naphthalene ND ug/L 0.5 EPA 524.2 yn 3/29/2007 n-Butylbenzene ND ug/L 0.5 EPA 524.2 yn 3/29/2007 n-Propylbenzene ND ug/L 0.5 EPA 524.2 yn 3/29/2007 p-Isopropyltoluene ND ug/L 0.5 EPA 524.2 yn 3/29/2007 sec-Butylbenzene ND ug/L 0.5 EPA 524.2 yn 3/29/2007 Styrene ND ug/L 0.5 100 EPA 524.2 yn 3/29/2007 tert-Butylbenzene ND ug/L 0.5 EPA 524.2 yn 3/29/2007 Tetrachloroethene ND ug/L 0.5 5.0 EPA 524.2 yn 3/29/2007 Toluene ND ug/L. 0.5 1000 EPA 524.2 yn 3/29/2007 Total xylenes ND ug/L 0.5 10000 EPA 524.2 yn 3/29/2007 trans-1,2-Dichloroethene ND ug/L 0.5 100 EPA 524.2 yn 3/29/2007 trans-l,3-Dichloropropene ND ug/L 0.5 EPA 524.2 yn 3/29/2007 Trichloroethene ND ug/L 0.5 5.0 EPA 524.2 yn 3/29/2007 Trichlorofluoromethane ND ug/L 0.5 EPA 524.2 yn 3/29/2007 Water sample meets the recommended limits for drinking water of all the above tested parameters. Approved By- (Lab ector)1 ND=None Detected RL = Reporting Limit MCL=Maximum Contaminant Level Superior Court House, PO.Box 427, Barnstable, MA 02630 Ph: 508-375-6605 LOCATION SEWAGE PERMIT NO. &'- q L�3 VILLAGE I N S T A LLER'S NAME A ADDRESS B U I L D E R OR OWN ER DATE PERMIT ISSUED DATE COMPLIANCE ISSUED � cl L0`C%A� ION SEWAGE PERMIT NOS• tit e a Lf 4 3 VILLAGE `Q_P a y l t INSTA LLER'S NAME i ADDRESS ` oc d U I L D E R OR OWNER_ DATE PERMIT ISSUED -- � DATE COMPLIANCE ISSUED d cr 1 � � CL C �� No...J... ......._.... , _............ THE COMMONWEALTH OF MASSACHUSETTS , BOAR® OF HEALTH t�r'`l'U...OF..... .✓- ....c.0............................... Appliratiun for Uiupusal VorkD Tomittrnrtiun truat Application is hereby made for a Permit to Construct (t,)"or Repair ( ) an Individual Sewage Disposal System at: Urr��cez�� 1��T ................__................_......_......----......._._ �.....�.........----------------------...._..... ...................................... �ocation-Address ,/J --_------or Lot No. fj- -- r ............... •...It............................................... ner Address a .............................. ............................................. -----.............----•---......---•-----..................-----•------........................... Installer Address /� , � Type of Building Size Lot......:.....................Sq. feet U Dwelling—No. of Bedrooms................3.......................Expansion Attic ( ) Garbage Grinder ( ) 'PLO_l Other—T e of Building No. of persons............................ Showers — Cafeteria Q' Other fixtures -----------------------------••. - Design Flow.............. ...................gallons per person per day. Total daily flow__-_.....33 ?._.._._.................gallons. WSeptic Tank—Liquid capacity.�'�..gallons Length..�..'Kf. Width_:!!?,G`.. Diameter__-__-_______-- Depth..�.`8`.� x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) `" Percolation Test Results Performed by.......-5 �''�__...�...:_.`fA L:......_.... Date..!`1°�.'.� ... I ,`4a Test Pit No. 1...4 -...minutes per inch Depth of Test Pit-__!.z ".... Depth to ground waler____�................. G14 Test Pit No. 2._4_16..minutes per inch Depth of Test Pit-----/�"... Depth to ground water........................ R+ --------•----------------------------------------------•----.-- -•••••......-•-•---•---•• - --------- ..................... 0 Description of Soil...... —./__8`..__.. iV LC?�-el-7--------•-•� ��---��'.•-�... ,�'l.... . ................ U ---- 4l �` .........................• ................................................. W -----•----•------------------•---•---•---••-------•---•-•---------------•---------------•-----------•----••--•------------•------•---------------------------•-•------•-----••--•--•................... UNature of Repairs or Alterations—Answer when applicable------------------------------------------------------------------------------------------------ ... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iITLI 5 of the State Sanitary Code—The ndersigned further agrees not to place the system in operatio -until a Certificate of pliance has e b he th. Signed......... . •••------------- •-•••--------•••--•--•----.........-•••--.... -•---(or , e Date Application Approved BY----------------- i. ... . -x,'-..........---.............._..•---- Date Application Disapproved for the following reasons:__...._.... .............................•-•-•-•------•-•---....----.._..---------------------........-•---.....-----•-------------------------•------••----....................................................... Date Permit No......................................................... Issued--•---------------------.........--- ^ .......---•- ---- Date No..... ._............ 4 � w THE COMMONWEALTH OF MASSACHUSETTS �BOARD OF HEALTH ............. ���.. ....oF... -5_7 C.................................... for Disposal Works Tonstrurtion Prrutit ""Application is hereby made for a Permit to Construct (v-�'or Repair ( ) an Individual Sewage Disposal System at: r Location Address �C .. / ,/�,wner ddress .......................... E: ia�a.. - .............._.._............_ .......---------•--...__._................_.............__...-----•......••........._..........__. Installer Address Tye of Building Size Lot__�%'��__F,�e.:.Sq. feet a Dwelling—No. of Bedrooms_______________3..__.___________________Expansion Attic ( ) Garbage Grinder ( ) 04 Other—Type of.:Building ____________________________ No. of persons............._.............. Showers ( ) — Cafeteria ( ) 04 Other fixtures .----•-•-----------•----•--- - W Design Flow.............. .....................gallons per person per day. Total daily flow---_____33v_..._._.... .__________.galIons. WSeptic Tank—Liquid capacity! __gallons Length_$_1G.".. Width�.,G...... Diameter................ Depth. r8�� x Disposal Trench—No. .................... Width.................... Total Length.................... Total,leaching area....................sq. ft. Seepage Pit No-_------------------ Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) _ '-' Percolation Pit NoRlsu!� -__.minutesmedr inch Depth Test t� -----••..--- Date_�`1____ __� �`y3 '•1 �� j .........►� P p l�Vth to ground water________________________ LN Test Pit No. 2_�_.15__minutes per inch Depth of Test Pit---- `_:_.. Dep1h`*-to ground water........................ a' -------------------- D Description of Soil----- ''_./-1'? o c. ...�' �_ _..... /N�....... x :.._._�f__. ?� I-•---------. •--- --------� ----•----...-•--•-.....--••--. WV./✓_-.��--..... ----•------------ ----------- VNature 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 TITIS 5 of the State Sanitary Code— Th ndersigned further agrees not to place the system in operatio until a Certificate of C�gmpliance has n b the y, alth. d lC ( Q I1 Signed ' -.. ..... ............................................. c +. .: Date Application Approved By................. ........................................ Date Application Disapproved for the following reasons--------------------------------•----•-------•-------------------------- ...................................... -•---•...................................................•----------•-----•------...:.--_-:-...-•--------------------------•-----•------------------------•------------•-----------•----•------•-•_-•- Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................O F..�J� T��✓rjC C .................................... Trr#ifiratr of TontpliFanrr THIS IS TO CERTIFY, ThatA? Individual Sewage Disposal System constructed (Lo-r-or Repaired ( ) by------- --••-------------------- ------•---_---- .............. 4.Ei t ns alter �+••-- 11` t has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No......................................... dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE....................................... _....✓ ..... Inspector........ .......................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH , 1.�.. !,,�.....OF...... ...... �.....T............................................... No....I1.�-........ FEE........................ Disposal rko o udion Trani# .!y!Permission is hereby granted _ ..... :��:T.................................................................... to Construc (✓f or Rep i� ( ),an Individual Sewage�D''sposal Sy _ at No.. =o'.�}.--•--F�C� -------•--==='� r....._...:✓.t �,�� Street � `,`� as shown on the application for Disposal Works Construction Permit No_____ _____________ Dated....._.-- _ ! �. -.-.-.... Sy(.rLiS.=H DATE_ f D' 4l �` Board of Health FORM 1255 A. M. SULKIN, INC., BOSTON Massachusetts Water Resources Commission/Division of Water Resources WATER WELL COMPLETION REPORT WELL TION Address-" L�C�dp go In I.A r1 42—City/Town 1n)a AI g _ G.S.Quadrangle Map Grid Location Owner i• -,1 V- Address_1 3_L —P a aA yo e,,L Y Ce a. qr✓t ` WELL USE CONSOLIDATED WELL Domestic Public ❑ Industrial ❑ Type of Water-bearing Rock Other Water-bearing Zones METHOD DRILLED 1) From—To— Rotary(type) AU Cable❑ 2) From To Other 3) From To 4) From To CASING Depth to Bedrock Length AO I Diameter � �l Type VC, UNCONSOLIDATED WELL' STATIC WATER LEVEL Water-bearing Materials Feet below land surface Jr Sand: fine❑ medium❑ coarse Date measured J 3-y Gravel: fine El medium❑ coarse❑ ' GRAVEL PACK WELL Screen: Yes No Slot*/0 ength from A 0 to a- > ❑ Split Screen(or 2nd screen) WATER QUALITY TESTS MADE Slog length from to Chemical (V Biological ❑ Depth To Bedrock PUMP TEST Drawdown feet after pumping days hours at GPM. How measured Recovery feet after hours. LOG of FORMATIONS COMMENTS: (On well or water) Materials From To C �S DRILLER L Firm CLIFFORD WELL DRILLING Address 65 Blue Rock Road City South Yarmouth, Mass. 02664 Re ' ration No. .2 rators t5ignature Please print irm y h 10M$181.164843 SN��- L of Z SN6�T5 3- Ito Go r �`� o► �,l9,5 r9 " ez, isB �y /So •r / ez,Zo•'¢ l 1 /0�1' LoT Z H po- pzz` b 40 Acees ze e, �P24, peoPosero p P. � w�u tq kk� 3 / 0, e � c-F 517,v 6 LOCATION .WE37 Bs}2.vsT�BGG: /y9S5 SCALE . �.��`. �. . . DATE .,y,99z .z✓ /y&¢ PLAN REFERENCE . 4B�-vc Lo7- Z'4 . . . . . . . . . . AlOTV-— EZZ-VA770N S ,BAsefD an/ d OF o� ED?R o� I CERTIFY THAT THE ... .. . _/ a SHOWN ON THIS PLAN IS LOCATED ON THE GROUND ELLEY AS SHOWN HEREON AND THAT IT CONFORMS TO THE No.26100 Z SETBACK REQUIREMENTS OF THE TOWN OF O t FG/ST£a�e WHEN CONSTRUCTED. 4#4SUBVEyo DATE : . . . . . . . . . . . 10e 7T/vtiG7z- REGISTERED LAND SURVEYOR � SHE�7- Z o f Z S.�fE�Ts a' > TOP OF FOUNDATION e CONCRETE COVER CONCRETE COVERS 4'�C71/74"PER. ��MAX. ` • PIPE 12"MAX. • EQUIV-) 4"ORANGEBURG(OR EQUIV.) PITC PIPE- MIN. LEACH PITCH 1/4"PER.FT. PIT PRECAST o,e J o' INVERT _ Q < LEACHING ° EL..?�c? INVERTINVERT e . ; PIT OR n'. SEPTIC TANK 3 DIST. 06 • w ; i;c EQUIV. ° INVERT BOX e; EL. Zo.00 /000.. .. GAL. INVERT 6• f-) „ � INVERT- o �: .`. 3/4 TO I V2� EL......... U. WASHED e I w STONE • I WDIA. DIA--+i��,..f�vn PROR LE OF GROUND WATER TABLE SEWAGE DISPOSAL SYSTEM NO SCALE S01 L LOG WITNESSED BY : DATE !`�Ay.�.�!9�3 TIME.!`':°f Tcv�/ / /Z,S. BOARD OF HEALTH TEST HOLE I TEST HOLE 2 STLT3o.� .2.yfru. �S. E N G I N E E R . . . Tap .So.t- np�sovc all 127 eve,/,go cep DESIGN DATA . NZ. /8,S0 &'Z. 17.3o NUMBER OF BEDROOMS 3 TOTAL ESTIMATED FLOW 33o GALLONS/DAY Grni� "rove BOTTOM LEACHING AREA ��3:/� . SQ.FT. /PIT Sao SIDE LEACHING AREA . . .? � ?' . . . SQ.FT./ PIT �NGrS G/NHS GARBAGE DISPOSAL . . !V4. . .(50% AREA INCREASE) TOTAL LEACHING AREA .3'39 3 . . SQ.FT /4-t -az. 8,00 /qy �. 1.80 PERCOLATION RATE 0-ss ?N?� �?�*�'. MIN/INCH LEACHING AREA PER PERCOLATION RATE SQ.FT. .N..? .WATER ENCOUNTERED NUMBER OF LEACHING PITS . APPROVED . . . . . . . . . . . . . BOARD OF HEALTH DATE . . . . . . . . . . AGENT OR INSPECTOR �P�SK Qf 4'gss OR HA ' E. S` ti W/UG�D N L/�si/fir KELLEY No.26100 q CISTEA�� WE3T �, .✓.s�r,98L� . . l40/sTEA�O SO AS%N URV PETITIONER , sE TOWN OF BARNS ABLE n 'u C:C %�' .�_---- SEWAGE # LOCATION � � _ASSESSOR'S MAP &LOT VILLAGE INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY f;? j LEACHING FACILITY: (type) (size) ( 3�,� �--- NO.OF BEDROOMS- 4 C BUILDER OR OWNER �xr PERMIT DATE: t� C, COMPLIANCE DATE: Separation Distance Between the: Feet Maximum Adjusted Groundwater Table and Bottom of Leaching Facility private Water supply 1 Well and Leaching Facility (If any wells exist Feet on site or within 200'feet of leaching any wetlands exist Feet facility) Edge of Wetland and Leaching Facility within 300 feet of leaching facility) Furnished by •J Atb � �I