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HomeMy WebLinkAbout0021 HIGHPOINT ROAD - Health 21 Highpoint Road Marstons Mills P A 028 042 I f � RECEI COMMONWEALTH OF MASSACHUSETTS JUL 1 5 2003 EXECUTIVE OFFICE OF ENVIRONMEN'._'AL AFFAI .STOWN OF sF--J: M1'ABtt HEALTH�EI'T. � Z v DEPARTMENT OF ENVIRONMENTAL PROTEC --_—""'—"_ � � d e TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUN":VARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYST ,M FORM PART A CERTIFICATION Property Address: 21 HIGHPOINT RD MARSTONS MILLS 02649 Owner's Name: GARY GAGNE Owner's Address: 21 HIGHIPOINT RD MARSTONS MILLS 02649 Date of Inspection: 6/25/03 Name of Inspector: (please print) JOHN GRACI, INC. Company Name: SEPTIC INSPECTIONS Mailing Address: P.O. BOX 2119 TEATICKET, NIA. 02536 Telephone Number: 508-564-6813 FAX 508-564-7270 CERTIFICATION STATEMENT I certify that 1 have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: X Passes _ Conditional asses _ Needs Furt Evaluation by the Local Approving Authority Fails Inspector's Signature: Date; 6/25/03 The system inspector shall submit copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspect on. 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 THE SYSTEM PASSES TITLE V INSPECTION. RECOMMOND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. ****This report only describes conditions at the time of inspection and under<�►e 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. Tit�� 5 Incirrtir�n F�rm /�15/�(1(1(1 � Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 21 HIGHPOINT RD MARSTONS MILLS 02649 Owner: GARY GAGNE Date of Inspection: 6/25/03 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: THE SYSTEM PASSES TITLE V INSPECTION.RECOMMOND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. 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 statements. If"not determined"please explain. n/a 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. ND explain: n/a n/a 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 _ obstruction is removed _ distribution box is leveled or replaced ND explain: n/a n/a 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: n/a Page 3 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 21 HIGHPOINT RD MARSTONS MILLS 02649 Owner: GARY GAGNE Date of Inspection: 6/25/03 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 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 n/a "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: n/a Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 21 HIGHPOINT RD MARSTONS MILLS 02649 Owner: GARY GAGNE Date of Inspection: 6/25/03 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all-inspections: Yes No X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X Liquid depth in cesspool is less than 6"below invert or available volume is less than '/2 day flow X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped NOT IN THE LAST YEAR INFO FROM OWNER. X Any portion of the SAS, cesspool or privy is below high ground water elevation. X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone 1 of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well. _ X 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 must be attached to this form.] NO (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 correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. a Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 21 HIGHPOINT RD MARSTONS MILLS 02649 Owner: GARY GAGNE Date of Inspection: 6/25/03 Check if the following have been done. You must indicate "yes" or"no" as to each of the following: Yes No X _ Pumping information was provided by the owner, occupant,or Board of Health X Were any of the system components pumped out in the previous two weeks X _ Has the system received normal flows in the previous two week period X Have large volumes of water been introduced to the system recently or as part of this inspection ? X _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) X _ Was the facility or dwelling inspected for signs of sewage back up? X _ Was the site inspected for signs of break out? X _ Were all system components,excluding the SAS, located on site'? X _ 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 ? X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems`? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no X _ Existing information. For example, a plan at the Board of Health. X _ 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 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 21 HIGHPOINT RD MARSTONS MILLS 02649 Owner: GARY GAGNE Date of Inspection: 6/25/03 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 5 Number of bedrooms(actual): 5 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 550 Number of current residents: 5 Does residence have a garbage grinder(yes or no): NO Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required] Laundry system inspected(yes or no): NO Seasonal use: (yes or no): NO Water meter readings, if available(last 2 years usage(gpd)) 000 Sump pump(yes or no): NO �� q Last date of occupancy: n/a '�(� Cam' COMMERCIAL/INDUSTRIAL Type of establishment: n/a Design flow(based on 310 CMR 15.203): n/agpd Basis of design flow(seats/persons/sqft,etc.): n/a Grease trap present(yes or no): NO Industrial waste holding tank present(yes or no): NO Non-sanitary waste discharged to the Title 5 system(yes or no): NO Water meter readings, if available: n/a Last date of occupancy/use: n/a OTHER(describe): n/a GENERAL INFORMATION Pumping Records Source of information: NOT IN THE LAST YEAR INFO FROM OWNER Was system pumped as part of the inspection (yes or no): NO If yes, volume pumped: n/agallons--How was quantity pumped determined? n/a Reason for pumping: n/a TYPE OF SYSTEM X 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 Other(describe): n/a . Approximate age of all components,date installed(if known)and source of information: REPAIRED IN 2000 INFO FROM ASBUILT Were sewage odors detected when arriving at the site(yes or no): NO Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 21 HIGHPOINT RD MARSTONS MILLS 02649 Owner: GARY GAGNE Date of Inspection: 6/25/03 BUILDING SEWER(locate on site plan) Depth below grade: 42" Materials of construction:_cast iron X40 PVC_other(explain): n/a Distance from private water supply well or suction line: n/a Comments(on condition of joints,venting, evidence of leakage,etc.): HOUSE IN ON TOWN WATER-BUT THERE IS A WELL PRESENT IN FRONT YARD SEPTIC TANK: X(locate on site plan) Depth below grade: 36" Material of construction: Xconcrete_metal_fiberglass_polyethylene other(explain)n/a If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate) Dimensions: H 10' 6" H 5' 7" W 5' 8`1 Sludge depth: 3" Distance from top of sludge to bottom of outlet tee or baffle: 31" Scum thickness: 3" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle is,, How were dimensions determined: MEASURED f Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): SEPTIC TANK AND ALL SEPTIC TANK COMPONENTS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. GREASE TRAP: _(locate on site plan) Depth below grade: n/a 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 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 7 Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 21 HIGHPOINT RD MARSTONS MILLS 02649 Owner: GARY GAGNE Date of Inspection: 6/25/03 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 gallons Design Flow: n/a gallons/day Alarm present(yes or no): N/A Alarm level: N/A Alarm in working order(yes or no): NO Date of last pumping: n/a Comments(condition of alarm and float switches,etc.): n/a DISTRIBUTION BOX: X(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE 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.): �s D-BOX IS STRUCTURALLY SOUND. PUMP CHAMBER: _(locate on site plan) Pumps in working order(yes or no): NO Alarms in working order(yes or no):NO Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): n/a R Page 9 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 21 HIGHPOINT RD MARSTONS MILLS 02649 Owner: GARY GAGNE Date of Inspection: 6/25/03 SOIL ABSORPTION SYSTEM (SAS): X (locate on site plan,excavation not required) If SAS not located explain why: n/a Type n/a leaching pits, number: n/a 500 GALLON CHAMBERS leaching chambers, number: 3 n/a leaching galleries, number: n/a n/a leaching trenches, number, length: n/a n/a leaching fields, number: n/a n/a overflow cesspool, number: n/a n/a innovative/alternative system Type/name of technology: n/a Comments(note condition of soil, signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.): THE LEACH FIELD IS FUNCTIONING PROPERLY.THE SYSTEM SHOWS NO SIGNS OF FAILURE. SOIL PROBED DRY.BOTTOM IS AT 7' 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 Dimensions of cesspool: n/a Materials of construction: n/a Indication of groundwater inflow(yes or no): NO Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a 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 4 Page 10 df 1 I � OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 21 HIGHPOINT RD MARSTONS MILLS 02649 Owner: GARY GAGNE Date of Inspection: 6/25/03 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permane:.t reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. �eet� n l® n AA y AC P� 3� lac in Page I Pof l 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 21 HIGHPOINT RD MARSTONS MILLS 02649 Owner: GARY GAGNE Date of Inspection: 6/25/03 SITE EXAM _Slope _Surface water _Check cellar Shallow wells Estimated depth to ground water 12+feet Please indicate(check)all methods used to determine the high ground water elevation: NO Obtained from system design plans on record- If checked,date of design roan reviewed: n/a YES Observed site(abutting property/observation hole within 150 feet of SAS) NO Checked with local Board of Health-explain: n/a NO Checked with local excavators, installers-(attach documentation) NO Accessed USGS database-explain: n/a You must describe how you established the high ground water elevation: GROUNDWATER DETERMINED FROM HAND AUGER- 12+ FEET s OWN OF BARNSTABLE r LOCATION ;2// SEWAGE # VILLAGE JJ'- M�lr. ASSESSOR'S MAP & LOT_10&__�V 00 INSTALLER'S NAME&PHONE NO.446 eA^41-7 775 'r SEPTIC TANK CAPACITY /5470 Ins LEACHING FACIL=: (type) G'/�r � (size), X �J NO. OF BEDROOMS ' BUILDER OR OWNS PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the 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 f .. O O � ' L i 1 5 7 i i • I 1 OWN OF BARNSTABLE dGe r LOCATIO SEWAGE # VILLAGE / A>�c� /�►•� 1� ASSESSOR'S MAP LOTAAL-6V INSTALLER'S NAME&PHONE NO./?046 7,75-> ae'00 SEPTIC TANK CAPACITY /500 ,'P n-f LEACHING FACELITY: (type) S (size)c5'2 X 1-5 NO. OF BEDROOMS BUILDER OR OWNER 9,4X A,&0, Q t PERMITDATE: COMPLIANCE DATE: — Separation Distance Between the: Maximum Adjusted Groundwater Table to the 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 -t=within 300 feet of leaching facility) Feet Furnished by F r61 .N 0 0 - s No. a mo y -^ i-fr 7 r Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS 0[ppfication for Migpogar *pgtem Cottgtruction Vermit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 1 14 t A 1 O i A f" Fa&, Owner's Name,Address and Tel.No. lrA I-Y 67A?n e. Assessor's Map/Parcel Q 1 Cj © q.A M\ _ Installer's Name,Addre*a&W f do Designer's Name,Address and Tel.No. 350 Main Street ,to ®A. W. Yarmouth, MA 0267$ Type of Building: Dwelling No.of Bedrooms- Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. P /Crud Description of Soil Nature of Repairs or Alterations(Answer when/a plicable)aau r„1 S 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 by this Board e _ Signed � "-�I Date S 1 "0 Application Approved by �..._ �"� is. ��;� Date__ .6 —1,4 -m u Application Disapproved for the following reasons Permit No. `1 ae; 16. Date Issued tw No._a4107 I? � \ Fee - r THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLES MASSACHUSETTS Application for MigosaY *ps�tem Construction Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components y __rr Location Address or Lot No. Q i �; / p; /�Uc`. Owner's Name,Address and Tel.No. C—A I',/ 67A 9 11 e Assessor's Map/Parcelxn �/j� (�/,w�\ Installer's Name,Address,�dl�ioCANCO Designer's Name,Address and Tel.No. S50 Main Street W. Yarmouth Type of Building: 4( Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures t Design Flow gallons per day. Calculated daily flow gallons. �. Plan Date Number of sheets Revision Date �'- Title Size of Septic Tank Type of S.A.S. 4 0 /vua 5'Ki J- s Description,of Soil Nature of Repairs or Alterations(Answer when a plicable) 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 by this Board of Ve4hh. _ Signed v/I ( 1 Date Application Approved by �.e.r... __ Date Application Disapproved for the following reasons Permit No. ,o®c. Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired(--j-Upgraded( ) Abandoned( )by 'v'r' O at d/ l Q; ,7` i2 /q/'f 7�.h /'l/1 l/$ has been constructed in accordance with the provisions of/Title 5 and the for Disposal System Construction Permit No._2,agg_ I$ :Z dated Installer Designer ., The issuance of this pe t sh 1 not be construed as a guarantee that the a wall function as d i ned. The issuance of this X�c*sh Date 0O Inspector I No. �Qo el— Fee S THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS xizpozar *pftem Construction Permit Permission is hereby granted to Construct(�)Repr( '�j Upgrade( )Abandon( ) System located at C) / r / 0144 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� + � r` 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, �� l� CQ,yi�lo.ti , hereby certify that the application for disposal works construction permit signed by me dated _ S- concerning the property located at C) d i meets all of the following criteria: h /• 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. /10 There are no wetlands within 100 feet bf 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 /• There are no variances requested or needed. 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] 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 Surface Elevation(using GIS information) 8 L B) G.W. Elevation +the MAX.High G.W. Adjustment DIFFERENCE BETWEEN A and B . SIGNED : y '1 CC", DATE: [Sketch proposed plan of system on back]. q:health folder:cert ca.� �• � t � r 17 �r�� ,. LOCATION! SEWAGE RMIIT 0. VILLAGE IN TA LLER'SAIpE & ADDRESS 0 UILOE R OR OWNER ,DATE PERMIT ISSUED � Al DATE COM ►LIANCE ISSUED S. / 33 V e cr- r THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH j -•..................... ..................OF.........................................------------------••••...........---............. Appliratiun for Diipuual Vorkg Tontitrudion rnmit Application is hereby made for a Permit to Construct ( ) or Repair ( individual Sewage Disposal System at . � �`-t --- ..__. ----------------------SOT --�,�--------..........-------------..........----------- �I ocation-Address or Lot No. �c. . .f � --------------•-----•------------•-------------- ............5..® ........................................................................ Ow r Address W ..........V.. ----------------------------------------- -----a �c;� f-( 4 5_._.0S c--- Installer Address Type of Building Size Lot_ _ __ -------- feet Dwelling—No. of Bedrooms._ .._ .3_ _....Expansion Attic ( ) Garbage Grinder ( ) 04 Other—Type of Building *' No. of persons.........I................. Showers ( ) — Cafeteria ( ) 04 Other fixtures ................................. W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. 9 Septic Tank—Liquid*capacity ...gallons Length................ Width...................... Diameter................ Depth................ xDisposal 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 ( ) aPercolation Test Results Performed by.......................................................................... Date------------------------------------ ,� Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water•-___________-__--__,__. Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ODescription of Soil........................................................................................................................................................................ x c, W -•••••----------------------•------•-----•-••...•••-----------•••••••---•-••...........••-••-------•----••... . Nature of Repairs or Alterations—Answer w a livable_____ /pJ_._---•-____._ U P P •--- - Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLL 5 of the State Sanois e undersigned further agrees not to place the system in operation until a Certificate of Compliance h t�oard of health. Signe .. -••---••-'•-•-••-•-••-.......•-------••.._.._--_- ---••--•-•••-DateApplication Approved BY --•--------_----------............... Date Application Disapproved for the following reasons:----------•-----•--•--------------------•----------.......-------------------------------------------------•---- ...............••••----•••---••-•--._.._..••-•-•••••-•••-•••-•-•••-••-••.....-••••---------••......._....I.....••••---•••-•...••••---•-•••-•-••-••••------------••••••--••••-••••-•--•••-•-••---•-•••_-•- Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS 4 BOARD OF HEALTH ..........................................OF.................................................................................... rdifiratr of f11untpfiaurr TIPI O T t the Individual Sewage D sposal System constructed ( ) or Repaired Y =. ._....... a at.._.. Z! -- —-•-------------------- ----------- has been installed in accord ce ith the provisions of T 5 of T�tate Sanitary C . _._/�' __. -?___._..._..._.... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATEE............................ 7--------------•---- Inspector-------, ..........................------........................... 1 .. IYo..?+�._F.Q'Z Fss..�� ..... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .................................OF.......................................................................................... ApptirFatiou for UWpaiial Workii Tomil.rnrtion hrmit Application is hereby made for a Permit to Construct ( ) or Repair ( "Individual Sewage Disposal System at: r ` I.o ................ ........ }........ Lt-N .....--------•--•--•---•---..............-- E. nAddress ooc .................................•------------ ._..... ..................__ y _ Own „�-� d�d�rg s t.....--•------------------------•------- GK!.� C t/ i3' �lf Yr/. �S a y_.. 1w•- i - .... � Installer Address �- -- ���^.� d Type of Building Size ---------Sq. feet V Dwelling—No. of Bedrooms..._ Expansion Attic ( ) Garbage Grinder ( ) -----•••....-•-•--•-----•- p�, Other—Type of Building .A G ! ..... o. of persons............................ Showers ( ) — Cafeteria ( ) a' Other fixtures ---------------------------------- ------ W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity -.!�O__gallons - Length................ Width................ Diameter------__--_-_- Depth................ 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.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water.....-................... (%4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ P4 0 Description of Soil.......:................................................................................................................................................................ x U --- -------------- -------------- -------------•-------------- ------------------------------------------ •----------------------------------------- ---------------------------------------------- W -•--••••----------------------------••••---•• ......-------- -•---•--------•-•-... ........................... - M ... w.......... ,-;�,.. � U Nature of Repairs or Alterations—Answer wlI pplicable------- ._►`�� �_ .�.._.----- �' ------ • ......... -----�, `J-l�C . ---- .... : :...--•-----------------------------------------------------------------•-----------------..•...........-- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of'TTT, . 5 of the State Sanitary dKyhe undersigned further agrees not to place the system in operation until a Certificate of Compliance has e iss the board of health. Si ne 4 g ---- -.:!�'--•-----------------------------•-•--••------------------------- -------------- ApplicationApproved BY ....----•----•--•---------------------••--•••-_... ........................................ Date Application Disapproved for the following reasons:---•----------•--------•----------------••-------•-•---•--------------------------------------••-•-•••......---_ ...........•...------•-------•----------------------•--------................--------.....-------------------------------------------•------------.....--------------------...•--.--•••.---••-•••---•--- Date PermitNo................................................--------- Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF..................................................................................... rr#ifiratr of TompliFanrr TH' Iy,,�O C7R'*?"I.'°_ ' the Individual Sewage Disposal System constructed ( ) or Repaired byrf ----- ? --------- ------------- a has been installed in accordan e ith the provisions of TI i r' j of Th tate Sanitar Co e a de i d in the application for Disposal Woks onstructlon Permit No.__-__ ................... `....._._. dated-----------__!�' THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.....................................1 aiglp'J--.---••-•---•--•-••-•. Inspector..----- ............................................................ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH OF............................................................. No......••-•--............ FEE........................ = ion rranit Permission is hereby granted.___ - >.:___'...:.._•v........ ....:. to Construct ,,o e air ( Indi ua isposal System at No.. ...r:: _ --. - ......:.-• ---- ` a Street as shown on the application for Dispo. Works Construction Permit No.- ........ Dated.......................................... Sd Board of Health DATE............. -•--- --------- ------------- FORM 1255 HOSES & WARREN. INC., PUBLISHERS No...94.6..:.. Faim..70�... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Appliratiun -fur Bhipnuttl Warkii Cnuntrurtiun Pernnit Application is hereby made for a Permit to Construct (t/�or Repair ( dividual Sewage Disposal System at: _ Add� ssoction- -W W L a Or / dress . t `•" ° .. Fl�l�/l2i/2ta1'e!;_4 ..n...T..�..... d/�/�..- _U X."rrJ�-----•---- Address / UType of Building Size Lot....r ,[ .....Sq. feet .� DwellingizNo. of Bedrooms------- `�________________ _____________Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ---------------------------- No. of persons............................ Showers ( ) — Cafeteria ( ) Q' Other fixtures ------------------------------- - - W Design Flow ,.?'-'-..................... .......gallons per person per day. Total daily flow------------�a� -�'_-_____--.-.--.--gallons. 9 Septic Tank—Liquid capacityf4;P-O-gallons Length................ Width................ Diameter---------------- Depth-.-.-_--_.----- xDisposal Trench—No..................... Width._...y_.__ ------ Total Length-------------------- Total leaching area----.r®�--------------------sq. ft. Seepage Pit No--------/---------- Diameter-----��a--- Depth below inlet__>�_�______ Total leaching area. („i ----sq. ft. z Other Distribution box ( Dosi - k - 1 '- Percolation Test Results Performed b ��- -- _:__'___---- . -/�G......12"0-�- Date ,j Pit No. 1................minutes per inch Depth of "Pest Pit_ __��___-_ Depth to ground water-. —107 . fi Test Pit No. 2......1......minutes per inch Depth of Test Pit- �_ `j. Depth to groundwater = _._:_ d R+' OF Mq�o= ... •-- 9 O Description of Soil__l -'o------`------cam` ` � �lr�� --"-- '0 i G+ !+J % V ---- - • Q ----------G:----------- y ............................. --------- ------ --//c - '� l.j:lF - ' r- k4 ��n��E cn Nature of.Repairs or Alterations—Answer when applicable............................................ No 11944 O. U -------------------------------------- ---------------------------------------------------PP -------------•---- �a� Agreement: FSS/0NAL The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accor . rth the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has be by the board of health. Sig `�-------- ----=11-4z 7 ate Application Approved BY ..............`G! f' ---- -- ------a----- ! ��Z 7 D to Application Disapproved for the following reasons:........................................................................................................_------ ------------------------------------------------------------•----------------------•---------•------------------------------------•-• ---•---------•-------------------•-----•---------------.-- Date PermitNo......................................................... Issued........................................................ Date s No.•. ` FEs. ..:..................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH -.. .. . ........OF........a...:a9. .../ rR 'lM`............................ App irtt#ion -for Biipaiitt1 Worko Towitrurtion Vrrmi# Application is hereby made for a Permit to Construct (,I�or Repair ( ) an Individual Sewage Disposal System t"14 : .� ................ .------------------..........--------•-- .............................-..... 4 Location. Ad ass o or6_.... r _--- �--�� t--- r Lot '. Address` �i._".=... ...�1r.9..G�..w..[---•%y'=�------- --••-.=�-e.-=�e.a...�-TT-�P--r-----/�/-�-�lr�i3.�t.._.. / I aller Address d Type of Buildin Size Lot_ ....Sq. feet U Dwelling� ._. _- ___ _ No. of Bedrooms._____ ------------------------------Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Q' Other fixtures _______________________________ _ _ d •-----------------------------------------•------•-----.--------•-----------•---------- W Design Flow-----_______________________'tiO...___.gallons per person per day. Total daily flow___-_______,- ________.._.__._..gallons. WSeptic Tank—Liquid capacitvf04?_gallons Length---------------- Width.-____---_-._ Diameter___._...._.____ Depth---.-____.._--- x Disposal Trench—No_____________________ Width_____,,______________ Total Length.................... Total leaching area--------------------sq. ft. Seepage Pit No.______-/.......... Diameter-----�"d__-.;Depth below inlet_6_'"O_--__ Total leaching , �'`.�.P/l ----- ft. Z Other Distribution box ( Dosin, �t nk Percolation Test Results Performed b _ __________________ ..._. ..._.__ Date----------- _ ,aa -el'd,�i''-Test' Pit No. 1________________minutes per inch Depth of Test Prt� __��_____. Depth to ground water.. ?___.-.:. (LI Test Pit No. 2......`______minutes per inch Depth of Test Pit.. _'__ _-- _ Depth to ground water��_�4�_�___.... --•--•--•------ -----•-- ------------- ---- •- -- - ---••---•----- Descriptionof Soil-- = -- -------- - ---------------- ----------------- -----------------_- ----------------- t}r W � �ic1.� .- c ----------------- s� y ------------------------- -----•---•----•-.--------------------- ---------•-----------•--------- rn� dOBER�..... G VNature of Repairs or Alterations—Answer when applicable------------------------------------------------------------- o--..--.----G,_-__.____.- ---------------------------------•-•-------------------------------•-----.---.--------•--•------••-•--------------_---------•--•------•-------------•-••------•------- �'- --p McGLONE cn ,O - Agreement: -o No.11944 ,Q FG �� The undersigned agrees to install the aforedescribed Individual Sewage Disposal System ' E the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to"pla i�U s� n operation until a Certificate of Compliance has b issu by the bo •rd of health. Sig e �42�.e..... ...........-•-- . ------ � --- Date Alication Approved B . .................. i 'I --- --- .: PP PP Y•--•- Date Application Disapproved for the following reasons:----•----------•--------•-•----------•--------•-------••---•-••-•-•----•-•---.....--•••-----------------------• ............................•-------------------------------------------..._-•--••••-•...----•--•---- Date PermitNo......................................................... Issued........... .............. ............................ Date THE COMMONWEALTH OF MASSACHUSETTSag BOARD OF HEALTH ............ .:.....0F....... l - . . �? .:................................. Trr#ifirtt#r of 10-10mlrlittttre THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (41�or Repairedby ( ) -'----•----••----• ---•------•--- . ---•------------••-••-••-••---•--•-•••-•---••-•---•----•--•-------------•••-----•--•-•-•-------•--- ,� nstaller // has been installed in accordance with the provisions of Article XI of The State Sanitary Code.,as described in the application for Disposal Works Construction Permit No----------------- _._..__. dated---:"V... 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 OFF HEALTH ........,�4 lsrt.. ...OF..........s✓,�✓ r? '+." �"... � � - No.---- -"- ......... FEE. ..................... �i����ttl r►rk,� C�,a��#rttr#i�at �rrmi# Permissionis hereby granted..........................................-------• •-------------•--•----------------------------- •------------------•---------•-.-----•- to Const�rTuct ( or e air ( ) .an Ind' 'd taI Sewage Disposal Systed Street as shown on the application for Disposal Works Construction Pe r it No._ _ . `_. Dated....��. "_r`` %.._. ..`�...__. ..................... ......................................... Board of Health DATE--------------= � FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS f R E Fee r^ ----9LI -- BOARD OF HEALTH TOWN OF BARNSTABLE 0(ppricat ion-*r V ell Con6trud ion permit Application is hereby made for a permit to Construct ( ), Alter ( ), or epair ( )an individual Well at: f0l _4--- -6-Y ---------- -------------------------------- Location — Address Assessors Map and Parcel 0 Owner — Ad2ress 1 cu-�-_W-dLI)rill-I'acu -------- -_ a5 __R#es__130- Installer_ DrillexG Address Da'AyV3 Type of Building Dwelling --- ------------------ --------- - Other - Type of Building----------------------- No. of Persons---------------------------------------- Type of Well—----- -- - --___-- - Capacity----- ---------------------------- ---- Purpose of Well--------- ---- --- -- ---- ------ Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation - The undersigned further agrees not to place the well in operation until ;Certificate of Compliance has been issued by the Board of Health. Signed -------- - -_____------------------------------------- ------------------------------------ date Application Approved B --- - - -= ---------------- �- PP PP Y- ' ` - date Application Disapproved for the following reasons:---------_______—_----_---------_---------_--------------_----_-------_____----______________ ------------------------------------------------------------------------------------ ---------------- ----- - --- - - - - a date Permit No.- --- f - - - Issued=- ---------------------------------------------------------------- ----- ---------------- date BOARD OF HEALTH TOWN OF BARNSTABLE Certificate ®f Compliance THIS IS TO CERTIFY, That the Individual Well Constructed ( ), Altered ( ), or Repaired (}� e . Installer _ at _- - _ A1 - -- ----- --- has been installed in accord ice with the provisions of the Town of Barnstable Board of Health Private Well Protection � - ,� - Regulation as described in the application for Well Construction-Permit No. -- - --- -Dated------------------------ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY,. DATE-------------------------------------------- ----------------------- Inspector---------------------------------------------------------------------------- No.;u---- - -- Fee-----•- --------- BOARD OF HEALTH TOWN OF BARNSTABLE 0(ppricationArWell Cootruction Permit Application is hereby made for a permit to Construct ( ), Alter ( ), or Repair ( )an individual Well at: 44 ,• 7 j i Location — Address Assessors Ma and Parcel � P ----------------------------- Owner Address _Nke-&LaYN WeA(_ r i I I c —--------------------- 'tt --------------- ------------------ ---- Installer — Driller`,) Address Q�119V3 Type of Building Dwelling— --- -- --- -- --- - Other - Type of Building -- No. of Persons--------------- Typeof Well----------------------------------------------------------------- Capacity -- - -- - -- Purpose of Well---------------___—_—___ Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation — The undersigned further agrees not to place the well in operation until,a.Certificate of Compliance has been issued by the Board of Health. Signed--=-------------.. -----------------___---------___ _ date— f Application Approved By 0. ^�^^ ).r,, —=''f =-- '`` /� �- / ---- U — —0--- ) ---_—_ -- •—date—_ °:--- Application Disapproved for the following reasons:---------------------- ---------------------- ----------- ------ ------- ------- -- — date Permit No. /—= --- -- -- Issued------______ _-- date BOARD OF HEALTH TOWN OF BARNSTABLE oor- (Certificate Of Compliance THIS IS TO CERTIFY, That the Individual Well Constructed ( ), Altered ( ), or Repaired ( ) Installer at 74 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-------------- A THE ISSUANCE OF THIS;CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE------------------------=------ ----------------------------- ----------------- Inspector- - - -- - - - ------ ---------------- i BOARD OF HEALTH 4 TOWN OF BARNSTABLE Yell Con5truct ion Permit No. -- �---/- Fee --- Permission is hereby granted — _n l l! f'ir_?,------------------------------ to Construct ( ), Alter ( ), 'o} Repair ( an Individual Well:at: No. - - - -— - -- - ----------------------------------------------------------- MA 80091� Street as shown on the application for a Well Construction Permit No.---- -- — -- -- ------- — —-- —— Dated--- t � V Board of Health DATE------—`---i— -- --- —------------ ._, �.t- " ,., ��f ��,. �� vti<iu 4�'�..<..,y,�0� t ♦w�°�'� +4w4siT��'vyY.veWua�AJ �u�iE+ii^v� .. uxu.:.0:aye.""" �y�� _ .n+e�^'.tiw..�.,� fir^" -'.." '�,.. a:wvx,a. "{.""'"""K"'^w�"'?^��iE'��`EifY�4�W11o5Ysr ,.., h a �s ,.�an,«iw..�..ei. .....�� �...�..-s=�_'...,.e.�.�.'�iv�-t t -:",.._ .. _.�..t:...».�.'�'r.,r,?x::es�«n•,r-,'..a' �; r _JL'n'i;:7Y�-'^..�.�7s�e':`""""''ain m..'`",�.+"+�A� V ,� � No. - -- --- =-- -==- ASSESSORS MAP N0: Fee--- =------ --- - - "OAR D OF HEALTH TOWN CWEL LE A.pplicat ion,forlVell Congtruct ion j3ernrit Application is hereby made for a permit to Construct ( ), Alter ( ), or Repair (4"*-)an individual Well at: RJ ------------ -------------------------------------------------------------------------- Location — Address f( Assessors Map and Parcel lil l -- h =J &--(---C--1---6------S--6--A---tG-i%t o ---------------------- Po� �1 ----- ASCCNOwner n6- X Address _ ------ ---- ------- Installer — l % Address Type of Building Dwelling---` ------- -------------------------------------------------- Other - Type of Building-------------------------------- No. of Persons------------------------------------------------- -!r Type of Well A —--Ro C - —�`' 1' #&AVA9��Capacity----------------------—-------------------------------- Purpose of Well-•Qpn6 ct 1L---------------------- ----------------- 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 Cert' scat of Compliance has been issued by the Board of Health. Signed ---- ---------------------------------------------- ------ ------------------------ date Application Approved B Yle!6L!ktLr r — — — —— — `= f Gate Application Disapproved for the following reasons:-------------------------------------------------------------------------date —---------- ------------------------------------------------------------------- -� date Permit No. ---- �`_ �-`��lS -- Issued--------- ~-`--6 -�— ---- -------------------- date BOARD OF HEALTH TOWN OF BARNSTABLE Certificate Of Compliance THIS IS TO CERTIFY, Pat the Individual Well Constructed ( ), Altered ( ), or Repaired ( �( bY---------------� — C c,�v..c L�---------------------—-----------------------------------------------—------------------------------------——— / / Installer & has been installed 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. 4�_< e- Kapted THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE------------------——— - —------------- — - Inspector------------------------------------------------------------------------------ + ice r � _ .`�• ,.. ,. .,, ,. � .. .. .. _._. ... ..K_ •-•,r. ...•,..v-,�,;,�:r„ .. No.- "-'-- 5! _�". � ` �`, �►' „) t* Fee--- _ t. BOARD OF HEALTH L.fI TOWN OF BARNS+ABLE R �ICicationore[[ CorigtrurtionVermit . is App'lic"ation is hereby made for a permit to—CeTqs uct ( ), Alter ( ), of Repair(!�jan ind'�id al Well at: I - --------- -—-�---- — -_ — — — - — — -- — — — — — — — — Location Add ,, Assessors Ma and Parcel er AJ CG N ti.� ------ --- --- /_ c'------;-------- G--I-) ---- r`" o b — , Inst er — Dnller r Address Type of Building ✓ /� Dwelling------- ------ ------------------------------------ Other - Ty of 13� ding------------------------------ No. of Persons---------------,----- -j--- -------;--------------- Type of Well-�!__- P_v t 1_i�l�/! Ca acit ---------------------------------------------------------- - ------ Purpose of Well ---------------------- -------- Agreement: ((� {- The undersigned agrees to install the aforedescribed indivrZlu% well tnaam6td� elw�th the provisions of The Town of arnstable Boar o Heaith--Priva-'—Fe Vq-e"rotection Regulation - -e-undbrii ned further agrees not to place the well in operation until a Cei icat .of Compliance,has been issued by the Board of Health. Signed ------ --- -- - ------- - g - -- date Application Approved B — -------- --- ------- L--- -- date Application Disapproved for the following reasons:------------------------------------------------------------------------------------- -------------- ------------- - -- - - ------------------------------------------------------------------------------------------------------------------------- date Permit No. ----- 7_ ~- ------------ Issued ---- "' 1__ - ---- ---------------------- date �� II �� �� �.�V. -... . , BOARD OF HEALTH TOWN OF BARNSTABLE Certificate ®f Compliance THIS IS TO CERTIFY, T_hat the Individual Well Constructed ( ), Altered ( ), or Repaired b --------------------------------------------------------— - --- —- f Installer at- MaiS7 / has been installed in accordance with the provisions of the Town of Barnstable Board fofHealth Private Well Protection --- Regulation as described in the application for Well Construction Permit No. -'-'�----g- - -- - ated---�-----�i-----�� THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. I DATE- --- ----—---— - ---— — -- Inspector---------------------------------------------—------------------------------ ;ih:i+:i.�dw..�:saa+a4A.�L..v�FL�e:.riwe..i.e....a.U.rW.w.rM.rt»aMs�....�.e..u.»...h..e,�M,..�+.�..�;K..wr.M.+APJ- � -. .. .. �� ;•_ ,.r; .-. - BOARD OF HEALTH TOWN OF BARNSTABLE Vell Congtruct ion Permit P � No. _% — Fee------------------- PermissionYce is hereby granted A /T---- t ---------------------------------------------------------------------------------- to Construct ( ), Alter ( ), or Repair an Individual Well.a No. ---------���--- —�o -" - J � �`�'�--- - ---------------------------------------------------------------------------------- Street as shown /on the p lication for a Well Construction Permit No. -Cl -" '—p- �-' Ora_- -- -- Dated - - � -------�_�____ -ate -7-'--=-----y-'�7----- Board of Health DATE lea, 12 dlfl9 D � loo A /,Q C� O /N� / � � �= 9��� `J '�.5!/= 7f•G°�Q.CEI/EL ��eZ �/Q�.?/'ij`;� �'�/f�,, /�'I/ �/�Jf// V���� V 0 0 0 ,O /���'�//G1/7 limo :• ,Q ��+ \9 " ° o .0 O. O O h i A D 3/� i�G�I/7 � 0 0 0�, 0 0 _` 'jam M1a f ✓/O/7d O/� Jr/c�2S /� ✓mil'''G°/GY�K .��� , a oft 14 d n° 0 O 0 0;o . . o e r/ �� TOT•9L /��ir�l/��'D'" f _ a o F gl Al OF ROBERT o Rt3BERT G. _ g y ` cGLQNE � Cdc�iLON , 'rg,raS^.• ' v M i 12057 .11944STi '�_. ;o�"Q,¢.����fc4 f 10 rl Yl nr 1�lKa_r R4AI U5,7,00 2�W • ���` �° ., , . y : P. ��, u/8,5' mach /r� accor�a�ce ti 612 Alt - �'`�. �rwt�r�� . -. � °` - - � _ � . /Mass. l of'�6✓mac do .